Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit as a Word Document. See example template below for required format.
Review the rubric for more information on how your assignment will be graded.
Demographic Data
Patient initial (one initial only), age, and gender must be Health Insurance Portability and Accountability (HIPPA) compliant.
Subjective
Chief Complaint (CC)
History of Present Illness (HPI)?(symptoms) in paragraph format
Past Medical History (PMH):?Current problem-focused and document pertinent information only.
Current Medications:
Medication Allergies:
Social History:?For current problem-focused and document only pertinent information only.
Family History: For current problem-focused and document only pertinent information only.
Review of Systems (ROS) as appropriate:
Objective
Vital signs
Mental Status Exam
Physical findings listed by body systems, not paragraph form.
Patient Health Questionnaires, Screenings, and the results (PHQ-9, GAD 7, suicidal)
Assessment (Diagnosis/ICD10 Code)
Include all diagnoses that apply to this visit.
Include one differential diagnosis.
Plan
Dx?Plan (lab, x-ray)
Tx?Plan: (meds)
Pt. Education, including specific medication teaching points.? ?
Safety Plan? ? ? ?
Referral/Follow-up
Mini SOAP Note
Mini SOAP Note
Criteria
Ratings
This criterion is
linked to a Learning
OutcomeSubjective
15 to >12.0 pts
Accomplished
SOAP format is well
organized, with C/C, History
of present Illness, past
medical history,
Medications, Allergies,
Social Hx, family history,
and other pertinent past and
current diagnostic details.
SOAP Note is complete,
concise, and relevant with no
extraneous data
12 to >10.0 pts
Satisfactory
SOAP format is well
organized, with C/C,
History of present Illness,
past medical history,
Medications, Allergies,
Social Hx, Family history,
and other pertinent past
and current diagnostic
details. Some extraneous
data is present, with one
minor data point missing.
10 to >5.0 pts
Needs Improvement
SOAP format analysis
is not well organized
or presented in a varied
format. Required data
is missing. Too much
extraneous data is
present, or 2-3 data
points are missing
5 to >0 pts
Unsatisfactor
Symptom anal
inadequate and
organized. Ob
or other data i
into the subjec
data. Critical d
missing
This criterion is
linked to a Learning
OutcomeObjective
15 to >12.0 pts
Accomplished
The Mental Status Exam is
complete, concise, wellorganized, and wellwritten. Includes pertinent
psychiatric information.
Organized by MSE list
format. No extraneous
information is included.
12 to >10.0 pts
Satisfactory
The Mental Status Exam
is partially incomplete,
organized, and
satisfactorily written.
Includes pertinent
psychiatric information
with additional extraneous
details included.
Somewhat organized in
MSE list format.
10 to >5.0 pts
Needs Improvement
The Mental Status
Exam is incomplete
and loosely organized,
with improvements
required. Therefore,
relevant psychiatric
information is omitted.
5 to >0 pts
Unsatisfactory
Mental Status Ex
absent, disorgani
presentation, adh
no specific forma
grossly omits rel
pertinent psychia
information.
Mini SOAP Note
Criteria
Ratings
This criterion is
linked to a Learning
OutcomeAssessment
15 to >12.0 pts
Accomplished
Diagnosis and
Differential Dx are
correct with DSM-5
code(s) and supported
by subjective and
objective data.
Includes: 1 working
Dx and 1 Differential
Dx.
12 to >10.0 pts
Satisfactory
Diagnosis and Differential
Dx are correct with DSM5 code(s) and supported
mainly by subjective and
objective data. One
pertinent differential
diagnosis is not listed
according to subjective
and objective data.
However, the working
diagnosis is correct.
10 to >5.0 pts
Needs Improvement
Diagnosis and Differential Dx
are correct with DSM-5
code(s) and supported mainly
by subjective and objective
data. Missing pertinent
differential diagnoses based
on subjective and objective
data presented. Or differential
diagnoses are adequate with
an incorrect working
diagnosis.
5 to >0 pts
Unsatisfactor
All diagnoses
(working and
differential
diagnoses) are
incorrect or m
based on the
subjective and
objective data
presented
This criterion is
linked to a Learning
OutcomePlan
15 to >12.0 pts
Accomplished
The plan is well-organized,
complete, evidence-based, and
patient-centric. It comprehensively
addresses the diagnosis and is
individualized to the specific
patient. *Plan requirements:
prescribed medications, if any;
explanation of off-label medication
use, if prescribed; risks and benefits
of medicines identified; therapy
recommendations; patient
education; referral/follow-up; and
health maintenance.
Total Points: 60
12 to >10.0 pts
Satisfactory
The plan is organized,
complete, evidencebased, and patientcentric. It
comprehensively
addresses the diagnosis
and is individualized to
the specific patient. The
plan is missing one of the
required items.
10 to >5.0 pts
Needs Improvement
The plan is less
organized and is not
based on evidence.
Fails to address each
diagnosis sufficiently
or is not individualized
or patient-centric The
plan is missing two or
more of the required
items.
5 to >0 pt
Unsatisfa
The plan
disorganiz
absent, or
missing a
required i
