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· Unit 14 Assignment – Clinical: SOAP Note
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Unit 14 Assignment – Clinical: SOAP Note
Instructions
Every other week students will choose one patient encounter to submit a Follow-up SOAP note for review.
Follow the rubric to develop your SOAP notes for this term.
The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.
Rubric
NU674 Unit 14 Assignment – Clinical: SOAP Note
NU674 Unit 14 Assignment – Clinical: SOAP Note
Criteria
Ratings
Pts
This criterion is linked to a Learning
OutcomeSubjective Information
3 pts
Level
5
Complete
and concise summary of pertinent information.
2 pts
Level
3
Well
organized; partial but accurate summary of pertinent information (>80%).
1 pts
Level
1
Poorly
organized and/or limited summary of pertinent information (50%-80%);
information other than “S” provided.
0 pts
Level
0
Less
than 50% of pertinent information is addressed; or is grossly incomplete
and/or inaccurate.
3 pts
This criterion is linked to a Learning
OutcomeObjective Information
3 pts
Level
5
Complete
and concise summary of pertinent information.
2 pts
Level
3
Partial
but accurate summary of pertinent information (>80%).
1 pts
Level
1
Poorly
organized and/or limited summary of pertinent information (50%-80%);
information other than “O” provided.
0 pts
Level
0
Less
than 50% of pertinent information is addressed; or is grossly incomplete
and/or inaccurate.
3 pts
This criterion is linked to a Learning
OutcomeAssessment: Problem
Identification and Prioritization
3 pts
Level
5
Complete
problem list generated and rationally prioritized; no extraneous information
or issues listed.
2 pts
Level
3
Most
problems are identified and rationally prioritized, including the “main”
problem for the case (>80%).
1 pts
Level
1
Some
problems are identified (50%-80%); incomplete or inappropriate problem
prioritization; includes nonexistent problems or extraneous information
included.
0 pts
Level
0
Less
than 50% of problems are listed; or main problem missed; or problems not
prioritized and/or identified nonexistent problems.
3 pts
This criterion is linked to a Learning
OutcomeAssessment: Assessment of
Current Psychiatric & Medical Condition(s) or Drug Therapy-related
Problem
3 pts
Level
5
An
optimal and thorough assessment is present for each problem.
2 pts
Level
3
An
assessment is present for each problem listed but not optimal.
1 pts
Level
1
Assessment
is present for 50-80% of problems
0 pts
Level
0
Less
than 50% of problems include an appropriate assessment.
3 pts
This criterion is linked to a Learning
OutcomeAssessment: Treatment Goals
3 pts
Level
5
Appropriate
and relevant therapeutic goals for each identified problem.
2 pts
Level
3
Appropriate
therapeutic goals for most identified problems (>80%).
1 pts
Level
1
Appropriate
therapeutic goals for a few identified problems (50%-80%).
0 pts
Level
0
Less
than 50% of problems have appropriate therapeutic goals.
3 pts
This criterion is linked to a Learning
OutcomePlan: Treatment Plan
3 pts
Level
5
Specific,
appropriate and justified recommendations (including drug name, strength,
route, frequency, and duration of therapy) for each identified problem.
2 pts
Level
3
Mostly
complete and appropriate for each identified problem (>80%).
1 pts
Level
1
Partially
complete and/or inappropriate for a few identified problems (50%-80%);
information other than “P” provided.
0 pts
Level
0
Less
than 50% of problems have an appropriate and complete treatment plan.
3 pts
This criterion is linked to a Learning
OutcomePlan: Counseling, Referral,
Monitoring & Follow-up
2 pts
Level
5
Specific
patient education points, monitoring parameters, follow-up plan and (where
applicable) referral plan for each identified problem.
1 pts
Level
3
Patient
education points, monitoring parameters, follow-up plan and referral plan
(where applicable) for >80% of identified problems.
0.5 pts
Level
1
Patient
education points, monitoring parameters, follow-up plan and referral plan
(where applicable) for a few identified problems (50%-80%).
0 pts
Level
0
Less
than 50% of problems include appropriate counseling, monitoring, referral
and/or follow-up plan.
2 pts
Total Points: 20
