NUR 612 Hypertension SOAP Note Subjective Assessment.

Distinguised Excellent Fair Poor Includes a direct quote from patient about presenting problem Includes a direct quote from patient and other unrelated information Includes information but information is NOT a direct quote Information is completely missing 4 Points Begins with patient initials, age, race, ethnicity and gender (5 demographics) 3 Points Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity and gender) 2 Points Begins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender) Information is completely missing 2 Points 1.5 Points 1 Points 0 Points Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) Includes the presenting problem and 7 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) Information is completely missing 5 Points 3 Points 2 Points 0 Points If allergies are present, students lists only the type of allergy name Information is completely missing 1 Points 0 Points Subjective Chief Complaint (Reason for seeking health care) Demographics History of the Present Illness (HPI) Allergies Includes NKA (including = Drug, If allergies are present, students lists type Drug, Environemental, Food, Herbal, and/or Latex environemtal factor, herbal, food, latex name and or if allergies are present (reports for each includes severity of allergy OR description of severity of allergy AND description of allergy allergy) 2 Points Review of Systems (ROS) 1.5 Points Includes 3 or fewer assessments for each body Includes 3 or fewer assessments for each body Includes a minimum of 3 assessments for each body system and assesses at least 9 system and assesses 5-8 body systems directed to system and assesses less than 5 body systems chief complaint AND uses the words “admits” directed to chief complaint

OR student does not body systems directed to chief complaint use the words “admits” and “denies” and “denies” AND uses the words “admits” and “denies” 12 Points 6 Points 3 Points 0 Points Information is completely missing 0 Points Objective Vital Signs Includes all 8 vital signs, (BP (with patient Includes 7 vital signs, (BP (with patient position), Includes 6 or less vital signs, (BP (with patient position), HR, RR, temperature (with HR, RR, temperature (with Fahrenheit or Celsius position), HR, RR, temperature (with Fahrenheit Fahrenheit or Celsius and route of and route of temperature collection), weight, or Celsius and route of temperature collection), Information is completely missing temperature collection), weight, height, BMI height, BMI (or percentiles for pediatric weight, height, BMI (or percentiles for pediatric (or percentiles for pediatric population) and population) and pain.) population) and pain.) pain.) 2 Points Labs Medications Includes a list of the labs reviewed at the visit, values of lab results and highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed. 3 Points Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency) 1.5 Points Includes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal values. 1 Points 0 Points Includes a list of the labs reviewed at the visit but does not include the values of lab results or Information is completely missing highlight abnormal values.

2 Points 1 Points Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including 3 of the 4: name, dose, medications route, frequency) Includes a list of all of the patient reported medications (including 2 of the 4: name, dose, route, frequency) 0 Points Information is completely missing Screenings Past Medical History 4 Points Includes an assessment of at least 5 screening tests 2 Points Includes an assessment of at least 4 screening tests 3 Points 2 Points Includes (Major/Chronic, Trauma, Includes (Major/Chronic, Trauma, Hospitaliztions), for each medical diagnosis, Hospitaliztions), for each medical diagnosis, year of diagnosis and whether the diagnosis either year of diagnosis OR whether the diagnosis is active or current is active or current 3 Points Past Surgical History Family History Social History 0 Points Information is completely missing 1 Points 0 Points Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current Information is completely missing 1 Points 0 Points Includes, for each surgical procedure, the Includes, for each surgical procedure, the year of Includes, for each surgical procedure but not the year of procedure and the indication for the procedure OR indication of the procedure year of procedure or indication of the procedure Information is completely missing procedure 3 Points Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer. 3 Points Includes all of the following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation. 3 Points Physical Examination 2 Points 1 Points Includes an assessment of at least 3 screening tests Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint 12 Points 2 Points 1 Points 0 Points Includes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer. Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer. Information is completely missing 2 Points 1 Points 0 Points Includes 10 of the 11 following: tobacco use, Includes 9 or less of the following: tobacco use, drug use, alcohol use, marital status, employment drug use, alcohol use, marital status, employment status, current/previous occupation, sexual status, current/previous occupation, sexual Information is completely missing orientation, sexually active, contraceptive use, orientation, sexually active, contraceptive use, and living situation. and living situation. 2 Points 1 Points 0 Points Includes a minimum of 3 assessments for each Includes a minimum of 2 assessments for each body system and assesses at least 4 body systems body system and assesses at least 4 body systems Information is completely missing directed to chief complaint directed to chief complaint 6 Points 3 Points 0 Points Assessment Diagnosis Includes a clear outline of the accurate Includes a clear outline of the accurate diagnoses principal diagnosis AND lists the remaining Includes an inaccurate diagnosis as the principal addressed at the visit but does not list the Information is completely missing diagnoses addressed at the visit (in diagnosis diagnoses in descending order of priority descending priority) 5 Points Differential Diagnosis 3 Points 2 Points 0 Points Includes at least 3 differential diagnoses for Includes 2 differential diagnoses for the principal Includes 1 differential diagnosis for the principal Information is completely missing the principal diagnosis diagnosis diagnosis 5 Points 3 Points Plan 2 Points 0 Points Pharmacologic treatment plan Diagnostic/Lab Testing Education Anticipatory Guidance Follow up plan Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”.

The plan includes ALL of the following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. Includes a detailed pharmacologic treatment plan Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under for each of the diagnoses listed under “assessment”. The plan includes less than 4 of “assessment”. The plan includes 4 of the the following: the drug name, dose, route, following 7: the drug name, dose, route, frequency, duration and cost as well as education frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis related to pharmacologic agent. If the diagnosis is is a chronic problem, student includes a chronic problem, student includes instructions instructions on currently prescribed medications on currently prescribed medications as above. as above. Information is completely missing 5 Points Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time” 5 Points 3 Points 2 Points 0 Points Includes appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing clinically required at this time” Includes appropriate diagnostic testing less than 50% of the time. Information is completely missing 3 Points 2 Points 0 Points Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives.

Includes at least 2 strategies to promote and develop skills for managing their illness and at least 2 self-management methods on how to incorporate healthy behaviors into their lives. Includes at least 1 strategies to promote and develop skills for managing their illness and at least 1 self-management methods on how to incorporate healthy behaviors into their lives. Information is completely missing 5 Points 3 Points 2 Points 0 Points Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening)) Includes at least 2 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))

Includes at least 1 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 1 secondary prevention strategies (related to age/condition (i.e. screening)) Information is completely missing 4 Points Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months) 4 Points 2 Points Includes recommendation for follow up, but does not include time frame (i.e. x # of days/weeks/months) 2 Points 1 Points 0 Points Does not include follow up plan 0 Points 0 Points Moderate level of APA precision Incorrect APA style Information is completely missing 3 Points 2 Points 1 Points 0 Points Free of grammar and spelling errors Writing mechanics need more precision and attention to detail Writing mechanics need serious attention 3 Points 2 Points 0 Points Writing References Grammar High level of APA precision 0 Points SOAP Note Template Encounter date: ________________________ Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____ Reason for Seeking Health Care: ______________________________________________ HPI:_________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________ Current perception of Health: Excellent Good Fair Poor Past Medical History • Major/Chronic Illnesses____________________________________________________ • Trauma/Injury ___________________________________________________________ • Hospitalizations __________________________________________________________ Past Surgical History___________________________________________________________ Medications: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Family History: ____________________________________________________________ Copyright © MVJ 2018 Social history: Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________ Employment Status: ______ Current/Previous occupation type: _________________ Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________ Sexual orientation: _______ Sexual Activity: ____ Contraception Use: ____________ Family Composition: Family/Mother/Father/Alone: _____________________________ Health Maintenance Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____ Exposures: Immunization HX: Review of Systems: General: HEENT: Neck: Lungs: Cardiovascular: Breast: GI: Male/female genital: Copyright © MVJ 2018 GU: Neuro: Musculoskeletal: Activity & Exercise: Psychosocial: Derm: Nutrition: Sleep/Rest: LMP: STI Hx: Physical Exam BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____ General: HEENT: Neck: Pulmonary: Cardiovascular: Breast: Copyright © MVJ 2018 GI: Male/female genital: GU: Neuro: Musculoskeletal: Derm: Psychosocial: Misc. Significant Data/Contributing Dx/Labs/Misc. Plan: Differential Diagnoses 1. 2. 3. Principal Diagnoses 1. Copyright © MVJ 2018 2. Plan Diagnosis Diagnostic Testing: Pharmacological Treatment: Education: Referrals: Follow-up: Anticipatory Guidance: Diagnosis Diagnostic Testing: Pharmacological Treatment: Education: Referrals: Follow-up: Anticipatory Guidance: Copyright © MVJ 2018 Signature (with appropriate credentials): __________________________________________ Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________ DEA#: 101010101 STU Clinic LIC# 10000000 Tel: (000) 555-1234 FAX: (000) 555-12222 Patient Name: (Initials)______________________________ Age ___________ Date: _______________ RX ______________________________________ SIG: Dispense: ___________ Refill: _________________ No Substitution Signature: ____________________________________________________________ Copyright © MVJ 2018 Copyright © MVJ 2018 Module 6 Assignment: SOAP Notes 3 Encounter Date: September 28, 2020 Patient Initials: G.M. Gender: Male Age: 54 Race: White Ethnicity: Hispanic Reason for Seeking Health Care “I feel extremely tired every day from morning to evening. I lack the energy to perform my activities. I’ve also noted a lump on my neck.” History of Present Illness A 54-year old white Hispanic male presented to the clinic complaining of persistent fatigue, loss of energy, and reduced productivity at work and his normal activities. The patient indicated that he works about 8 hours as a chef in a restaurant but has lost job motivation four months ago. He reports frequent bouts of reduced mood, decreased appetite, sleepiness, and weakness in the extremities that are transiently relieved by rest. NUR 612 Hypertension SOAP Note Subjective Assessment.

The symptoms have worsened over the last two months, especially after standing for long hours at work. He falls asleep immediately when he reaches home and does not spend time chatting with his neighbors as before. Additionally, he noted for two months, his motivation to work has reduced. He feels unusually colder than the people around him. Further, during this period, he has noted gradual growth Copyright © MVJ 2018 of a neck mass that is now associated with the throat fullness and soreness. He has gained weight significantly despite reduced appetite. He says that his vision was fine but has blurred for the last month. He fears taking large meals because of the frequent  occurrence of constipation. Allergies G.M. denies any allergies. He does not have any allergies to environ NUR 612 Hypertension SOAP Note Subjective Assessment.NUR 612 Hypertension SOAP Note Subjective Assessment.