Mount Royal University Hypertension Acute Conditions Soap Note Paper

Soap Note 1 Acute Conditions
Soap Note 1 Acute Conditions (15 Points) Due 06/15/2019
Pick any Acute Disease from Weeks 1-5 (see syllabus)
Soapnotes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarismprogram)
Turn itin Score must be less than 50% or will not be accepted for credit, must be yourown work and in your own words. You can resubmit, Final submission will beaccepted if less than 50%. Copy paste from websites or textbooks will not beaccepted or tolerated. Please see College Handbook with reference to AcademicMisconduct Statement.
Late Assignment Policy
Assignments turned in late will have 1 point taken off for every day assignment is late, after 7 days assignment will get grade of 0. No exceptions

Follow the MRU Soap Note Rubric as a guide:
Grading Rubric
Student______________________________________
This sheet is to help you understand what we arelooking for, and what our margin remarks might be about on your write ups ofpatients. Since at all of the white-ups that you hand in are uniform, thisrepresents what MUST be included in every write-up.
1) Identifying Data(___5pts): The opening list of the note. Itcontains age, sex, race, marital status, etc. The patient complaint should begiven in quotes. If the patient has more than one complaint, each complaintshould be listed separately (1, 2, etc.) and each addressed in the subjectiveand under the appropriate number.
2) Subjective Data(___30pts.): This is the historical part of thenote. It contains the following:
a) Symptom analysis/HPI(Location, quality ,quantity or severity, timing, setting, factors that make it better or worse,and associate manifestations.(10pts).
b) Review of systems of associated systems,reporting all pertinent positives and negatives (10pts).
c) Any PMH, family hx, social hx, allergies,medications related to the complaint/problem (10pts). If more than one chiefcomplaint, each should be written u in this manner.
3)Objective Data(__25pt.): Vital signs need to be present. Height andWeight should be included where appropriate.
a)Appropriatesystems are examined, listed in the note and consistent with those identifiedin 2b.(10pts).
b)Pertinentpositives and negatives must be documented for each relevant system.
c)Any abnormalities must be fully described.Measure and record sizes of things (likes moles, scars). Avoid using “ok”,”clear”, “within normal limits”, positive/ negative, and normal/abnormal todescribe things. (5pts).
4) Assessment (___10pts.):Diagnoses should be clearly listed and worded appropriately.
5) Plan (___15pts.): Be sureto include any teaching, health maintenance and counseling along with thepharmacological and non-pharmacological measures. If you have more than onediagnosis, it is helpful to have this section divided into separate numberedsections.
6) Subjective/ Objective, Assessment andManagement and Consistent (___10pts.): Does the note support the appropriatedifferential diagnosis process? Is there evidence that you know what systemsand what symptoms go with which complaints? The assessment/diagnoses should beconsistent with the subjective section and then the assessment and plan. Themanagement should be consistent with the assessment/ diagnoses identified.
7) Clarity of the Write-up(___5pts.): Is itliterate, organized and complete?

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