Assignment Prompt & Instructions
– ## ASOAPnoteisamethodofdocumentationemployedbyhealthcareproviderstorecordandcommunicatepatientinformationinaclear.docx
– ## SOAPNoteTemplate-1.docx
– ## SoapNoterubric.docx
**## ASOAPnoteisamethodofdocumentationemployedbyhealthcareproviderstorecordandcommunicatepatientinformationinaclear.docx**
A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.
**Instructions:**
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
| | |
| — | — |
| **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. |
| **P** = | Plan: Treatment, diagnostic testing, and follow up |
**## SOAPNoteTemplate-1.docx**
| | |
| — | — |
| SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
| _Demographics_ | |
| _Chief Complaint (Reason for seeking health care)_ | |
| _History of Present Illness (HPI)_ | |
| _Allergies_ | |
| _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
| _Vital Signs_ | |
| _Labs_ | |
| _Medications_ | |
| _Past Medical History_ | |
| _Past Surgical History_ | |
| _Family History_ | |
| _Social History_ | |
| _Health Maintenance/ Screenings_ | |
| _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
| _Diagnosis_ | |
| _Differential Diagnosis_ | |
| _ICD 10 Coding_ | |
| _Pharmacologic treatment plan_ | |
| _Diagnostic/Lab Testing_ | |
| _Education_ | |
| _Anticipatory Guidance_ | |
| _Follow up plan_ | |
| _Prescription_ | See Below (scroll down) |
| _References_ | |
| _Grammar_ | |
| |
| — |
| EA#: 101010101 STU Clinic LIC# 10000000 |
| Tel: (000) 555-1234 FAX: (000) 555-12222 |
| Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |
Signature (with appropriate credentials):_____________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
**## SoapNoterubric.docx**
| | |
| — | — |
| Demographics | **1 to >0.8 pts**<br>**Begins with patient initials, age, race, ethnicity and gender (5 demographics)** |
| Chief Complaint (Reason for seeking health care) | **4 to >3 pts**<br>**Includes a direct quote from patient about presenting problem** |
| History of the Present Illness (HPI) | **5 to >3 pts**<br>**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**<br>**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) | **2 to >1.5 pts**<br>**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 | **4 to >2 pts**<br>**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**<br>**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**<br>**Includes, for each surgical procedure, the year of procedure and the indication for the procedure** |
| | |
| — | — |
| Family History | **3 to >2 pts**<br>**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**<br>**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**<br>**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**<br>**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**<br>**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**<br>**Includes at least 3 differential diagnoses for the principal diagnosis** |
| Pharmacologic treatment plan | **5 to >3 pts**<br>**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**<br>**Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”** |
| Education | **3 to >2 pts**<br>**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**<br>**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**<br>**Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)** |
| Prescription | **3 to >2 pts**<br>**Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials** |
| | |
| — | — |
| Writing Mechanics, Citations, and APA Style | **3 to >2 pts**<br>**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.** |
**## SoapNoterubric.docx**
| | |
| — | — |
| Demographics | **1 to >0.8 pts**<br>**Begins with patient initials, age, race, ethnicity and gender (5 demographics)** |
| Chief Complaint (Reason for seeking health care) | **4 to >3 pts**<br>**Includes a direct quote from patient about presenting problem** |
| History of the Present Illness (HPI) | **5 to >3 pts**<br>**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**<br>**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) | **2 to >1.5 pts**<br>**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 | **4 to >2 pts**<br>**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**<br>**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**<br>**Includes, for each surgical procedure, the year of procedure and the indication for the procedure** |
| | |
| — | — |
| Family History | **3 to >2 pts**<br>**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**<br>**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**<br>**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**<br>**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**<br>**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**<br>**Includes at least 3 differential diagnoses for the principal diagnosis** |
| Pharmacologic treatment plan | **5 to >3 pts**<br>**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**<br>**Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”** |
| Education | **3 to >2 pts**<br>**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**<br>**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**<br>**Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)** |
| Prescription | **3 to >2 pts**<br>**Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials** |
| | |
| — | — |
| Writing Mechanics, Citations, and APA Style | **3 to >2 pts**<br>**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.** |
**## ASOAPnoteisamethodofdocumentationemployedbyhealthcareproviderstorecordandcommunicatepatientinformationinaclear.docx**
A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.
**Instructions:**
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
| | |
| — | — |
| **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. |
| **P** = | Plan: Treatment, diagnostic testing, and follow up |
**## SOAPNoteTemplate-1.docx**
| | |
| — | — |
| SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
| _Demographics_ | |
| _Chief Complaint (Reason for seeking health care)_ | |
| _History of Present Illness (HPI)_ | |
| _Allergies_ | |
| _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
| _Vital Signs_ | |
| _Labs_ | |
| _Medications_ | |
| _Past Medical History_ | |
| _Past Surgical History_ | |
| _Family History_ | |
| _Social History_ | |
| _Health Maintenance/ Screenings_ | |
| _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
| _Diagnosis_ | |
| _Differential Diagnosis_ | |
| _ICD 10 Coding_ | |
| _Pharmacologic treatment plan_ | |
| _Diagnostic/Lab Testing_ | |
| _Education_ | |
| _Anticipatory Guidance_ | |
| _Follow up plan_ | |
| _Prescription_ | See Below (scroll down) |
| _References_ | |
| _Grammar_ | |
| |
| — |
| EA#: 101010101 STU Clinic LIC# 10000000 |
| Tel: (000) 555-1234 FAX: (000) 555-12222 |
| Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |
Signature (with appropriate credentials):_____________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
**## SoapNoterubric.docx**
| | |
| — | — |
| Demographics | **1 to >0.8 pts**<br>**Begins with patient initials, age, race, ethnicity and gender (5 demographics)** |
| Chief Complaint (Reason for seeking health care) | **4 to >3 pts**<br>**Includes a direct quote from patient about presenting problem** |
| History of the Present Illness (HPI) | **5 to >3 pts**<br>**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**<br>**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) | **2 to >1.5 pts**<br>**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 | **4 to >2 pts**<br>**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**<br>**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**<br>**Includes, for each surgical procedure, the year of procedure and the indication for the procedure** |
| | |
| — | — |
| Family History | **3 to >2 pts**<br>**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**<br>**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**<br>**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**<br>**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**<br>**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**<br>**Includes at least 3 differential diagnoses for the principal diagnosis** |
| Pharmacologic treatment plan | **5 to >3 pts**<br>**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**<br>**Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”** |
| Education | **3 to >2 pts**<br>**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**<br>**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**<br>**Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)** |
| Prescription | **3 to >2 pts**<br>**Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials** |
| | |
| — | — |
| Writing Mechanics, Citations, and APA Style | **3 to >2 pts**<br>**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.** |
**## ASOAPnoteisamethodofdocumentationemployedbyhealthcareproviderstorecordandcommunicatepatientinformationinaclear.docx**
A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.
**Instructions:**
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
| | |
| — | — |
| **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. |
| **P** = | Plan: Treatment, diagnostic testing, and follow up |
**## SOAPNoteTemplate-1.docx**
| | |
| — | — |
| SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
| _Demographics_ | |
| _Chief Complaint (Reason for seeking health care)_ | |
| _History of Present Illness (HPI)_ | |
| _Allergies_ | |
| _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
| _Vital Signs_ | |
| _Labs_ | |
| _Medications_ | |
| _Past Medical History_ | |
| _Past Surgical History_ | |
| _Family History_ | |
| _Social History_ | |
| _Health Maintenance/ Screenings_ | |
| _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
| _Diagnosis_ | |
| _Differential Diagnosis_ | |
| _ICD 10 Coding_ | |
| _Pharmacologic treatment plan_ | |
| _Diagnostic/Lab Testing_ | |
| _Education_ | |
| _Anticipatory Guidance_ | |
| _Follow up plan_ | |
| _Prescription_ | See Below (scroll down) |
| _References_ | |
| _Grammar_ | |
| |
| — |
| EA#: 101010101 STU Clinic LIC# 10000000 |
| Tel: (000) 555-1234 FAX: (000) 555-12222 |
| Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |
Signature (with appropriate credentials):_____________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
**## SoapNoterubric.docx**
| | |
| — | — |
| Demographics | **1 to >0.8 pts**<br>**Begins with patient initials, age, race, ethnicity and gender (5 demographics)** |
| Chief Complaint (Reason for seeking health care) | **4 to >3 pts**<br>**Includes a direct quote from patient about presenting problem** |
| History of the Present Illness (HPI) | **5 to >3 pts**<br>**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**<br>**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) | **2 to >1.5 pts**<br>**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 | **4 to >2 pts**<br>**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**<br>**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**<br>**Includes, for each surgical procedure, the year of procedure and the indication for the procedure** |
| | |
| — | — |
| Family History | **3 to >2 pts**<br>**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**<br>**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**<br>**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**<br>**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**<br>**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**<br>**Includes at least 3 differential diagnoses for the principal diagnosis** |
| Pharmacologic treatment plan | **5 to >3 pts**<br>**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**<br>**Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”** |
| Education | **3 to >2 pts**<br>**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**<br>**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**<br>**Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)** |
| Prescription | **3 to >2 pts**<br>**Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials** |
| | |
| — | — |
| Writing Mechanics, Citations, and APA Style | **3 to >2 pts**<br>**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.** |
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