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• Unit 11 Assignment – Clinical: SOAP Notes
Immersive Reader
Unit 11 Assignment – Clinical: SOAP Notes
Instructions
Each week students will choose one patient encounter to submit a Follow-up SOAP note for review.
Follow the rubric to develop your SOAP notes for this term.
The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.
Rubric
NU673 Unit 11 Assignment – Clinical: SOAP Note
NU673 Unit 11 Assignment – Clinical: SOAP Note
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeSubjective Information 3 pts
Level 5
Complete and concise summary of pertinent information. 2 pts
Level 3
Well organized; partial but accurate summary of pertinent information (>80%). 1 pts
Level 1
Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “S” provided. 0 pts
Level 0
Less than 50% of pertinent information is addressed; or is grossly incomplete and/or inaccurate.
3 pts
This criterion is linked to a Learning OutcomeObjective Information 3 pts
Level 5
Complete and concise summary of pertinent information. 2 pts
Level 3
Partial but accurate summary of pertinent information (>80%). 1 pts
Level 1
Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “O” provided. 0 pts
Level 0
Less than 50% of pertinent information is addressed; or is grossly incomplete and/or inaccurate.
3 pts
This criterion is linked to a Learning OutcomeAssessment: Problem Identification and Prioritization 3 pts
Level 5
Complete problem list generated and rationally prioritized; no extraneous information or issues listed. 2 pts
Level 3
Most problems are identified and rationally prioritized, including the “main” problem for the case (>80%). 1 pts
Level 1
Some problems are identified (50%-80%); incomplete or inappropriate problem prioritization; includes nonexistent problems or extraneous information included. 0 pts
Level 0
Less than 50% of problems are listed; or main problem missed; or problems not prioritized and/or identified nonexistent problems.
3 pts
This criterion is linked to a Learning OutcomeAssessment: Assessment of Current Psychiatric & Medical Condition(s) or Drug Therapy-related Problem 3 pts
Level 5
An optimal and thorough assessment is present for each problem. 2 pts
Level 3
An assessment is present for each problem listed but not optimal. 1 pts
Level 1
Assessment is present for 50-80% of problems 0 pts
Level 0
Less than 50% of problems include an appropriate assessment.
3 pts
This criterion is linked to a Learning OutcomeAssessment: Treatment Goals 3 pts
Level 5
Appropriate and relevant therapeutic goals for each identified problem. 2 pts
Level 3
Appropriate therapeutic goals for most identified problems (>80%). 1 pts
Level 1
Appropriate therapeutic goals for a few identified problems (50%-80%). 0 pts
Level 0
Less than 50% of problems have appropriate therapeutic goals.
3 pts
This criterion is linked to a Learning OutcomePlan: Treatment Plan 3 pts
Level 5
Specific, appropriate and justified recommendations (including drug name, strength, route, frequency, and duration of therapy) for each identified problem. 2 pts
Level 3
Mostly complete and appropriate for each identified problem (>80%). 1 pts
Level 1
Partially complete and/or inappropriate for a few identified problems (50%-80%); information other than “P” provided. 0 pts
Level 0
Less than 50% of problems have an appropriate and complete treatment plan.
3 pts
This criterion is linked to a Learning OutcomePlan: Counseling, Referral, Monitoring & Follow-up 2 pts
Level 5
Specific patient education points, monitoring parameters, follow-up plan and (where applicable) referral plan for each identified problem. 1 pts
Level 3
Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for >80% of identified problems. 0.5 pts
Level 1
Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for a few identified problems (50%-80%). 0 pts
Level 0
Less than 50% of problems include appropriate counseling, monitoring, referral and/or follow-up plan.
2 pts
Total Points: 20
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