Your SOAP note should be clear and concise and students will lose points for improper grammar, p

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: ____________________________________________________________

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:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosoci

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 3 Points 2 Points 0 Points
Begins with patient initials, age, race,
ethnicity and gender (5 demographics)

Begins with 4 of the 5 patient demographics
(patient initials, age, race, ethnicity and gender)

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

Includes NKA (including = Drug,
Environemental, Food, Herbal, and/or Latex
or if allergies are present (reports for each

severity of allergy AND description of
allergy)

If allergies are present, students lists type Drug,
environemtal factor, herbal, food, latex name and

includes severity of allergy OR description of
allergy

If allergies are present, students lists only the
type of allergy name Information is completely missing

2 Points 1.5 Points 1 Points 0 Points

Includes a minimum of 3 assessments for
each body system and assesses at least 9
body systems directed to chief complaint

AND uses the words ??admits? and ??denies?

Includes 3 or fewer assessments for each body
system and assesses 5-8 body systems directed to

chief complaint AND uses the words ??admits?
and ??denies?

Includes 3 or fewer assessments for each body
system and assesses less than 5 body systems

directed to chief complaint OR student does not
use the words ??admits? and ??denies?

Information is completely missing

12 Points 6 Points 3 Points 0 Points

Includes all 8 vital signs, (BP (with patient
position), HR, RR, temperature (with

Fahrenheit or Celsius and route of
temperature collection), weight, height, BMI
(or percentiles for pediatric population) and

pain.)

Includes 7 vital signs, (BP (with patient position),
HR, RR, temperature (with Fahrenheit or Celsius