Submit a Problem-Focused SOAP note here for grading. You must use an actual pati

Submit a Problem-Focused SOAP note here for grading. You must use an actual patient from your clinical practicum. Review the rubric for more information on how your assignment will be graded. Be sure to use the SOAP note template for your program and view the rubric associated with your program for details on how your assignment will be graded.
Psychiatric Mental Health NP Students
PMH- NP Template: PMHNP SOAP Note TemplateDownload PMHNP SOAP Note Template
PMH-NP Grading Rubric: PMHNP SOAP Note RubricDownload PMHNP SOAP Note Rubric
Rubric
N682L-A SOAP Note Rubric
N682L-A SOAP Note Rubric
CriteriaRatingsPts
This criterion is linked to a Learning OutcomeS (Subjective)
10 ptsAccomplished
Symptom analysis is well organized, with C/C, OLD CART, pertinent negatives, and pertinent positives. All data needed to support the diagnosis & differential are present. Is complete, concise, and relevant with no extraneous data.
5 ptsSatisfactory
Symptom analysis well organized with C/C, OLD CART, pertinent negatives, and pertinent positives. Some extraneous data is present and/or one minor data point missing.
2.5 ptsNeeds Improvement
Symptom analysis is not well organized. Data is missing. There is too much extraneous data and/or 2-3 minor data points missing
0 ptsUnsatisfactory
Symptom analysis is inadequate, is not organized. Objective or other data is mixed into the subjective data. Important data is missing.
10 pts
This criterion is linked to a Learning OutcomeO (Objective)
10 ptsAccomplished
Complete, concise, well organized, well written, and includes pertinent positive and pertinent negative physical findings. Organized by body system in list format. No extraneous data.
5 ptsSatisfactory
All relevant exams were done thoroughly but extraneous exams were also done. It is somewhat organized in list format.
2.5 ptsNeeds Improvement
Symptom analysis is not well organized. Data is missing. There is too much extraneous data and/or 2-3 minor data points missing.
0 ptsUnsatisfactory
Omitted important relevant exams and/or subjective data are included. Lacking organization.
10 pts
This criterion is linked to a Learning OutcomeA (Assessment)
10 ptsAccomplished
Diagnosis and differential dx are correct, include ICD code, and are supported by subjective and objective data.
5 ptsSatisfactory
Diagnosis is correct with ICD codes and is supported by subjective and objective data. Differential diagnosis was inaccurate based on subjective and objective data.
2.5 ptsNeeds Improvement
Diagnosis is correct but either does not include ICD code or is missing two or more important differential diagnoses according to the subjective and objective data provided.
0 ptsUnsatisfactory
Diagnosis is not correct, is not provided or is not reflective of the subjective and objective data provided.
10 pts
This criterion is linked to a Learning OutcomeP (Plan)
10 ptsAccomplished
Plan is organized, complete and supported with 2 evidence-based references. Addresses each diagnosis and is individualized to the specific patient and includes medication teaching and all 5 components: (Dx plan, Tx plan, patient education, referral/follow-up, health maintenance).
5 ptsSatisfactory
Plan is organized, complete and evidence-based according to National Standards of Care. Addresses each diagnosis and is individualized to the specific patient and includes medication teaching but may be missing 1-2 minor points.
2.5 ptsNeeds Improvement
Plan is less organized and not based on evidence according to the National Standards of Care. Does not address each diagnosis or may not be individualized to the specific patient. Missing medication teaching or one of the 5 components.
0 ptsUnsatisfactory
No Plan provided or is not organized. Does not address all diagnoses identified and/or does not include all 5 components of plan, including medication teaching.
10 pts
Total Points: 40