OSCE SOAP Note Assignment
After the on-campus OSCE, students will complete a SOAP note in a word document on their assigned patient and submit here. Attached is an example of the format students should follow (there are several examples located in your 5342 textbooks and Maxwell’s Quick Medical Reference in the History and Physical section).
For the OSCE patient encounter, use point form for your subjective and objective portions. Students will not be expected to document a treatment plan for the patient, but are expected to document potential diagnoses and ICD 10 codes appropriate to the patient encounter. You may as a guide for your SOAP note. Review the rubric to be sure to cover everything required. Be sure not to omit CHM (current health maintenance) and DDx (differential diagnosis). For DDx, choose 1 symptom from the CC and discuss 3 possible etiologies (see module 2 for more).
Please include an APA formatted title/cover page, and cite the resource(s) used for your SOAP note format (i.e. Bickley, Maxwell, other).
Rubric
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CC Introductory Data & Chief Complaint (CC) • Intro includes the date seen. • CC is a brief statement • uses patient’s/ parent’s/guardian’s voice (i.e. uses quotation marks.)
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HPI History of Present Illness (HPI) • Includes 9 attributes of a symptom • If this is a follow-up visit, includes reason for visit, current problems and their treatment, recent relevant lab work, last medication monitoring, recent side effects or complaints related to the problems under treatment. • Documentation indicates student has a clear understanding of how to obtain an HPI and of how to document it.
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ROS Review of Systems (ROS) • Includes pertinent positive and negative data in 10 or more systems with 3 or more relevant attributes for each, and no errors in documentation (i.e. does not include objective data in any part of the ROS). • Documents fully and accurately using correct terminology.
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Past Medical History (PMH), Family History (FH), & Social History (SH) • Includes all required content (see health assessment textbook) for each category listed (PMH, FH, and SH). Includes age at diagnosis and, for FH, age at death and cause of death (COD). • FH includes 3 generations: patient’s biological siblings, patient’s biological parents, and patient’s biological grandparents. (Children may replace grandparents if unknown.) Affirms presence and absence of specific disorders in PMH and FH rather than documenting “negative” or “unremarkable.” • Documentation is expected to show that the student inquired about a comprehensive list of conditions which the patient “denied” or “acknowledged”. • Documentation is thorough, clear, logical, and appropriate.
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CHM Current Health Maintenance (CHM) • Includes documentation of the appropriate topics for the age of the patient in the case study based on the following list: (1) Review of current medications (includes dosages and frequencies), (2) statement about use or nonuse of alternative treatments, (3) statement about allergies or no known allergies to medications, (4) review of immunization status, (5) developmental assessment, (6) dietary assessment, (7) dental care assessment – daily hygiene practices and frequency of checkups, (8) safety issues appropriate for age, (9) sleep patterns. • Documentation of appropriate topics requiring education and/or anticipatory guidance, based on the above review is comprehensive and well done. • It is obvious the student has a strong grasp of the topic.
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PE Physical Exam (PE) • Includes objective data, only. • Includes VS, BMI, and 10 body systems. • Pertinent positives and negatives are identified. • Documentation is clear, uses medical terminology and is accurate.
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Differential & Concluding Diagnosis • Identifies 3 appropriate differential diagnoses with ICD 10 code. • Justifies each using references to support. • Identifies an appropriate concluding diagnosis based on the above.
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APA APA Formatting criteria include the following: • Correct reference list sources and source citation in the narrative • Correct headings consistent with the grading rubric section titles • Uses point form for S and O portions. Work flows in a logical manner and is easy to read.
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