SOAP NOTE 1: PEDIATRIC
1. SOAP Notes: Students must submit at least four SOAP notes, 1 weekly beginning the third week of the semester. These notes should be de-identified with no protected patient data included. Each note should have a different diagnosis to show the variety of the visits the student is experiencing. These will receive remarks from seminar leaders and should show progression throughout the semester. If the seminar leader feels there is not enough progression the student will be required to continue to turn in notes until proficiency has been reached.
SOAP Note Rubric
Key points: SOAP = Subjective, Objective, Assessment, and Plan. A common mistake students make is to combine the ROS (review of systems) with the physical exam. However, the ROS is subjective—what the patient tells you. The PE is objective: your observation through examining the patient. The ROS belongs in the Subjective portion and the Physical exam belongs in the Objective portion of the note. For assessment section please provide additional differential diagnoses of what the patient might be presenting with, making note of the actual diagnosis form the list of differentials.
Use OLDCARTS for history of present illness:
OLDCARTS Onset; Location; Duration; Characteristic; Alleviating and aggravating factors; Radiation or relieving factors; Timing; and Severity.