Pease complete a SOAP Note analysis based on the following information: SOAP Note Attached, Example of an analysis attached
Rubric SOAP
Case Analysis SOAP GRADING RUBRIC with Cultural interventions
Guidelines:
1-Choose a client from your clinical setting & write up a case analysis (see below for content).
2- SOAP note from your clinical should be included (remove all patient identifiers)
SUBJECTIVE Analysis (10 POINTS) Score received
1- Compare & contrast subjective section with literature
taking into consideration the following criteria;
a-Identified and collected the necessary data including the
patients culture
b-Categorized and organized data using the appropriate format
c-Incorporated all pertinent data/facts
d- Used proper documentation
OBJECTIVE Analysis (10 POINTS) Score received
1- Compare & contrast objective section with literature taking into consideration the following criteria
a. Identified and collected the necessary data
b. Categorized and organized data using the appropriate format
c.Incorporated all pertinent data/facts
d. Used proper documentation
ASSESSMENT Analysis (35 POINTS) Score received
1- Compare & contrast subjective section with literature taking into consideration the following criteria
a-Filtered relevant data from irrelevant data
b.-Interpreted relationships/patterns among data (e.g., noted trends)
c.Integrated information to arrive at diagnosis
d.Identified risk factors
e. Differentials listed & discussed in comparison to actual diagnosis
e. Used proper documentation
PLAN Analysis (35 POINTS) Score received
1- Compare & contrast subjective section with literature taking into consideration the following criteria
a. Recommended an appropriate plan for each problem
b-Included recommendations for non-drug and drug therapy
c-Included recommendations for monitoring
d- Included health education
e- Included follow-up& referrals
f. Incorporate any cultural interventions which were done specifically for this patient
FORMAT ( 10 POINTS) Score received
1- APA
2- References Current
3- Writing clear, concise
4- Summary/Conclusion
TOTAL
** The patient’s culture must be identified and an intervention regarding the culture should be addressed in the plan.
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