SOAP note for Trichomoniasis Infection.
I am providing a template and also an example of the SOAP and guidelines. S =Subjective data: Patient’s Chief Complaint (CC).O =Objective data: Including client behavior, physical assessment, vital signs, and meds.A =Assessment: Diagnosis of the patient’s condition. Include differential diagnosis PP =Plan: Treatment, diagnostic testing, and follow up. Remember this is a gynecological SOAP Note, and it should include GTPAL system in the beginning of HPI. Remember to use citations for diagnosis, medications, anticipatory guidance, Just follow the example I have attached below.
Demographics
1 to >0.8 pts
Begins with patient initials, age, race, ethnicity and gender (5 demographics)
Chief Complaint (Reason for seeking health care)
4 to >3 pts
Includes a direct quote from patient about presenting problem
History of the Present Illness (HPI)
5 to >3 pts
Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)
Allergies
2 to >1.5 pts
Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)
Review of Systems (ROS)
15 to >8 pts
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”
Vital Signs
2 to >1.5 pts
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.)
Labs
2 to >1.5 pts
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.
Medications
4 to >2 pts
Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)
Past Medical History
3 to >2 pts
Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current
Past Surgical History
3 to >2 pts
Includes, for each surgical procedure, the year of procedure and the indication for the procedure
Family History
3 to >2 pts
Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.
Social History
3 to >2 pts
Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.
Health Maintenance / Screenings
3 to >2 pts
Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests
Physical Examination
15 to >8 pts
Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint.
Diagnosis
5 to >3 pts
Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)
Differential Diagnosis
5 to >3 pts
Includes at least 3 differential diagnoses for the principal diagnosis
ICD 10 Coding
3 to >2 pts
Correctly includes all ICD-10 codes relevant to the diagnoses addressed at the visit
Pharmacologic treatment plan
5 to >3 pts
Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required 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.
Diagnostic / Lab Testing
3 to >2 pts
Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”
Education
3 to >2 pts
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.
Anticipatory Guidance
3 to >2 pts
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))
Follow Up Plan
2 to >1 pts
Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)
Prescription
3 to >2 pts
Prescription includes all required components: patient information, date, drug name, dose,
Writing Mechanics, Citations, and APA Style
3 to >2 pts
Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials
