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[Solved] SOAP note about a geriatic patient.

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Template and rubric are included. – ## SOAPNoteTemplate.docx – ## SOAPNoteRubric1.pdf **## SOAPNoteTemplate.docx** | | | | — | — | | SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance | | _Demographics_ | | | _Chief Complaint (Reason for seeking health care)_ | | | _History of Present Ill…

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Template and rubric are included.

– ## SOAPNoteTemplate.docx

– ## SOAPNoteRubric1.pdf

**## SOAPNoteTemplate.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])

**## SOAPNoteRubric1.pdf**

SOAP Note Rubric

Criteria Ratings Point
s

Demographics 1 to >0.8 pts
Begins with patient
initials, age, race,
ethnicity and
gender (5
demographics)

0.8 to >0.25 pts
Begins with 4 of
the 5 patient
demographics
(patient initials,
age, race,
ethnicity and
gender)

0.25 to
>0.0 pts
Begins with 3
or less patient
demographics
(patient
initials, age,
race, ethnicity
and gender)

0 pts
Missing
criteria
and/or
submission
.

1
point

Chief
Complaint
(Reason for
seeking health
care)

4 to >3.0 pts
Includes a direct
quote from patient
about presenting
problem

3 to >2.0 pts
Includes a direct
quote from
patient and
other unrelated
information

2 to >0.0 pts
Includes
information
but
information is
NOT a direct
quote

0 pts
Missing
criteria
and/or
submission
.

4
points

History of the
Present
Illness (HPI)

5 to >3.0 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)

3 to >2.0 pts
Includes the
presenting
problem and 7
of the 8
dimensions of
the problem
(OLD CARTS –
Onset, Location,
Duration,
Character,
Aggravating
factors,
Relieving
factors, Timing
and Severity)

2 to >0.0 pts
Includes the
presenting
problem and 6
of the 8
dimensions of
the problem
(OLD CARTS –
Onset,
Location,
Duration,
Character,
Aggravating
factors,
Relieving
factors,
Timing and
Severity)

0 pts
Missing
criteria
and/or
submission
.

5
points

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)

1.5 to >1.0 pts
If allergies are
present,
students lists
type Drug,
environmental
factor, herbal,
food, latex name
and includes
severity of
allergy OR
description of
allergy

1 to >0.0 pts
If allergies are
present,
students lists
only the type
of allergy
name

0 pts
Missing
criteria
and/or
submission
.

2
points

Review of
Systems
(ROS)

15 to >8.0 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”

8 to >3.0 pts
Includes 3 or
fewer
assessments for
each body
system and
assesses 5-8
body systems
directed to chief
complaint AND
uses the words
“admits” and
“denies”

3 to >0.0 pts
Includes 3 or
fewer
assessments
for each body
system and
assesses less
than 5 body
systems
directed to
chief
complaint OR
student does
not use the
words
“admits” and
“denies”

0 pts
Missing
criteria
and/or
submission
.

15
points

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.)

1.5 to >1.0 pts
Includes 7 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.)

1 to >0.0 pts
Includes 6 or
less vital
signs, (BP
(with patient
position), HR,
RR,
temperature
(with F or C
and route of
temperature
collection),
weight, height,
BMI (or
percentiles for
pediatric
population)
and pain.)

0 pts
Missing
criteria
and/or
submission
.

2
points

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.

1.5 to >1.0 pts
Includes a list of
the labs
reviewed at the
visit, values of
lab results but
does not
highlight
abnormal
values.

1 to >0.0 pts
Includes a list
of the labs
reviewed at
the visit but
does not
include the
values of lab
results or
highlight
abnormal
values.

0 pts
Missing
criteria
and/or
submission
.

2
points

Medications 4 to >2.0 pts
Includes a list of all
of the patient
reported
medications and
the medical
diagnosis for the
medication
(including name,

2 to >1.0 pts
Includes a list of
all of the patient
reported
medications and
the medical
diagnosis for
the medication
(including 3 of

1 to >0.0 pts
Includes a list
of all of the
patient
reported
medications
(including 2 of
the 4: name,

0 pts
Missing
criteria
and/or
submission
.

4
points

dose, route,
frequency)

the 4: name,
dose,
medications
route,
frequency)

dose, route,
frequency)

Past Medical
History

3 to >2.0 pts
Includes
(Major/Chronic,
Trauma,
Hospitalizations),
for each medical
diagnosis, year of
diagnosis and
whether the
diagnosis is active
or current

2 to >1.0 pts
Includes
(Major/Chronic,
Trauma,
Hospitalizations)
, for each
medical
diagnosis, either
year of
diagnosis OR
whether the
diagnosis is
active or current

1 to >0.0 pts
Includes each
medical
diagnosis but
does not
include year of
diagnosis or
whether the
diagnosis is
active or
current

0 pts
Missing
criteria
and/or
submission
.

3
points

Past Surgical
History

3 to >2.0 pts
Includes, for each
surgical procedure,
the year of
procedure and the
indication for the
procedure

2 to >1.0 pts
Includes, for
each surgical
procedure, the
year of
procedure OR
indication of the
procedure

1 to >0.0 pts
Includes, for
each surgical
procedure but
not the year of
procedure or
indication of
the procedure

0 pts
Missing
criteria
and/or
submission
.

3
points

Family History 3 to >2.0 pts
Includes an
assessment of at
least 4 family
members
regarding, at a
minimum, genetic
disorders, diabetes,
heart disease and
cancer.

2 to >1.0 pts
Includes an
assessment of
at least 3 family
members
regarding, at a
minimum,
genetic
disorders,
diabetes, heart
disease and
cancer.

1 to >0.0 pts
Includes an
assessment of
at least 2
family
members
regarding, at a
minimum,
genetic
disorders,
diabetes, heart
disease and
cancer.

0 pts
Missing
criteria
and/or
submission
.

3
points

Social History 3 to >2.0 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.

2 to >1.0 pts
Includes 10 of
the 11 required
following:
tobacco use,
drug use,
alcohol use,
marital status,
employment
status,
current/previous
occupation,
sexual
orientation,
sexually active,
contraceptive

1 to >0.0 pts
Includes 9 or
less of the
required
information.

0 pts
Missing
criteria
and/or
submission
.

3
points

use, and living
situation.

Health
Maintenance /
Screenings

3 to >2.0 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

2 to >1.0 pts
Includes a
partial
assessment of
immunization
status and
health
maintenance
needs, missing
some key
components.
Includes an
assessment of
at least 4
screening tests

1 to >0.0 pts
Includes
minimal
assessment of
immunization
status and
health
maintenance
needs, lacking
detail.
Includes an
assessment of
at least 3
screening
tests

0 pts
Missing
criteria
and/or
submission
.

3
points

Physical
Examination

15 to >8.0 pts
Includes a
minimum of 4
assessments for
each body system
and assesses at
least 5 body
systems directed to
chief complaint

8 to >3.0 pts
Includes a
minimum of 3
assessments for
each body
system and
assesses at
least 4 body
systems
directed to chief
complaint

3 to >0.0 pts
Includes a
minimum of 2
assessments
for each body
system and
assesses at
least 4 body
systems
directed to
chief
complaint

0 pts
Missing
criteria
and/or
submission
.

15
points

Diagnosis

5 to >3.0 pts
Includes a clear
outline of the
accurate principal
diagnosis AND lists
the remaining
diagnoses
addressed at the
visit (in descending
priority)

3 to >1.0 pts
Includes a clear
outline of the
accurate
diagnoses
addressed at the
visit but does
not list the
diagnoses in
descending
order of priority

1 to >0.0 pts
Includes 1
differential
diagnosis for
the principal
diagnosis

0 pts
Missing
criteria
and/or
submission
.

5
points

Differential
Diagnosis

5 to >3.0 pts
Includes at least 3
differential
diagnoses for the
principal diagnosis

3 to >1.0 pts
Includes at least
2 differential
diagnoses for
the principal
diagnosis

1 to >0.0 pts
Includes at
least 1
differential
diagnoses for
the principal
diagnosis

0 pts
Missing
criteria
and/or
submission
.

5
points

ICD 10 Coding 3 to >2.0 pts
Correctly includes
all ICD-10 codes
relevant to the
diagnoses
addressed at the
visit

2 to >1.0 pts
Correctly
includes most
ICD-10 codes
relevant to the
diagnoses
addressed at the
visit

1 to >0.0 pts
Includes some
ICD-10 codes
relevant to the
diagnoses
addressed at
the visit

0 pts
Missing
criteria
and/or
submission
.

3
points

Pharmacologi
c treatment
plan

5 to >3.0 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.

3 to >1.0 pts
Includes a
detailed
pharmacologic
treatment plan
for each of the
diagnoses listed
under
“assessment”.
The plan
includes 4 of the
required
following 7: the
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.

1 to >0.0 pts
Includes a
detailed
pharmacologi
c treatment
plan for each
of the
diagnoses
listed under
“assessment”.
The plan
includes less
than 4 of the
information:

0 pts
Missing
criteria
and/or
submission
.

5
points

Diagnostic /
Lab Testing

3 to >2.0 pts
Includes
appropriate
diagnostic/lab
testing 100% of the
time OR
acknowledges “no
diagnostic testing
clinically required
at this time”

2 to >1.0 pts
Includes
appropriate
diagnostic/lab
testing 50% of
the time OR
acknowledges
“no diagnostic
testing clinically
required at this
time”

1 to >0.0 pts
Includes
appropriate
diagnostic
testing less
than 50% of
the time.

0 pts
Missing
criteria
and/or
submission
.

3
points

Education 3 to >2.0 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.

2 to >1.0 pts
Includes at least
2 strategies to
promote and
develop skills
for managing
their illness and
at least 2 self-
management
methods on how
to incorporate
healthy
behaviors into
their lives.

1 to >0.0 pts
Includes at
least 1
strategies to
promote and
develop skills
for managing
their illness
and at least 1
self-
management
methods on
how to
incorporate

0 pts
Missing
criteria
and/or
submission
.

3
points

healthy
behaviors into
their lives

Anticipatory
Guidance

3 to >2.0 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))

2 to >1.0 pts
Includes at least
2 primary
prevention
strategies
(related to
age/condition
(i.e.
immunizations,
pediatric and
pre-natal
milestone
anticipator
guidance)) and
at least 2
secondary
prevention
strategies
(related to
age/condition
(i.e. screening))

1 to >0.0 pts
Includes at
least 1 primary
prevention
strategies
(related to
age/condition
(i.e.
immunizations
, pediatric and
pre-natal
milestone
anticipatory
guidance))
and at least 1
secondary
prevention
strategies
(related to
age/condition
(i.e.
screening))

0 pts
Missing
criteria
and/or
submission
.

3
points

Follow Up
Plan

2 to >1.0 pts
Includes
recommendation
for follow up,
including time
frame (i.e. x # of
days/weeks/months
)

1 to >0.0 pts
Includes recommendation for
follow up, but does not include
time frame (i.e. x # of
days/weeks/months)

0 pts
Missing
criteria
and/or
submission
.

2
points

Prescription 3 to >2.0 pts
Prescription
includes all
required
components:
patient information,
date, drug name,
dose, route,
frequency, quantity
to be dispensed,
refills, and
provider’s
signature and
credentials

2 to >1.0 pts
Prescription
includes most
required
components,
but is missing 1-
2 elements such
as quantity to be
dispensed or
refills

1 to >0.0 pts
Prescription is
missing 3 or
more required
components
such as
patient
information,
date, or
provider’s
signature

0 pts
Missing
criteria
and/or
submission
.

3
points

Writing
Mechanics,
Citations, and
APA Style

3 to >2.0 pts
Effectively uses the
literature and other
resources to inform
their work.
Exceptional use of
citations and
extended
referencing. APA

2 to >1.0 pts
Moderately use
the literature
and other
resources to
inform their
work.
Moderately use
of citations and

1 to >0.0 pts
Ineffectively
uses the
literature and
other
resources to
inform their
work.
Ineffectively

0 pts
Missing
criteria
and/or
submission
.

3
points

style is correct, and
writing is free of
grammar and
spelling errors.

extended
referencing. APA
style and writing
mechanics need
more precision
and attention to
detail.

use of
citations and
extended
referencing.
APA style and
writing
mechanics
need serious
attention.

Total 100

**## SOAPNoteRubric1.pdf**

SOAP Note Rubric

Criteria Ratings Point
s

Demographics 1 to >0.8 pts
Begins with patient
initials, age, race,
ethnicity and
gender (5
demographics)

0.8 to >0.25 pts
Begins with 4 of
the 5 patient
demographics
(patient initials,
age, race,
ethnicity and
gender)

0.25 to
>0.0 pts
Begins with 3
or less patient
demographics
(patient
initials, age,
race, ethnicity
and gender)

0 pts
Missing
criteria
and/or
submission
.

1
point

Chief
Complaint
(Reason for
seeking health
care)

4 to >3.0 pts
Includes a direct
quote from patient
about presenting
problem

3 to >2.0 pts
Includes a direct
quote from
patient and
other unrelated
information

2 to >0.0 pts
Includes
information
but
information is
NOT a direct
quote

0 pts
Missing
criteria
and/or
submission
.

4
points

History of the
Present
Illness (HPI)

5 to >3.0 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)

3 to >2.0 pts
Includes the
presenting
problem and 7
of the 8
dimensions of
the problem
(OLD CARTS –
Onset, Location,
Duration,
Character,
Aggravating
factors,
Relieving
factors, Timing
and Severity)

2 to >0.0 pts
Includes the
presenting
problem and 6
of the 8
dimensions of
the problem
(OLD CARTS –
Onset,
Location,
Duration,
Character,
Aggravating
factors,
Relieving
factors,
Timing and
Severity)

0 pts
Missing
criteria
and/or
submission
.

5
points

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)

1.5 to >1.0 pts
If allergies are
present,
students lists
type Drug,
environmental
factor, herbal,
food, latex name
and includes
severity of
allergy OR
description of
allergy

1 to >0.0 pts
If allergies are
present,
students lists
only the type
of allergy
name

0 pts
Missing
criteria
and/or
submission
.

2
points

Review of
Systems
(ROS)

15 to >8.0 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”

8 to >3.0 pts
Includes 3 or
fewer
assessments for
each body
system and
assesses 5-8
body systems
directed to chief
complaint AND
uses the words
“admits” and
“denies”

3 to >0.0 pts
Includes 3 or
fewer
assessments
for each body
system and
assesses less
than 5 body
systems
directed to
chief
complaint OR
student does
not use the
words
“admits” and
“denies”

0 pts
Missing
criteria
and/or
submission
.

15
points

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.)

1.5 to >1.0 pts
Includes 7 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.)

1 to >0.0 pts
Includes 6 or
less vital
signs, (BP
(with patient
position), HR,
RR,
temperature
(with F or C
and route of
temperature
collection),
weight, height,
BMI (or
percentiles for
pediatric
population)
and pain.)

0 pts
Missing
criteria
and/or
submission
.

2
points

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.

1.5 to >1.0 pts
Includes a list of
the labs
reviewed at the
visit, values of
lab results but
does not
highlight
abnormal
values.

1 to >0.0 pts
Includes a list
of the labs
reviewed at
the visit but
does not
include the
values of lab
results or
highlight
abnormal
values.

0 pts
Missing
criteria
and/or
submission
.

2
points

Medications 4 to >2.0 pts
Includes a list of all
of the patient
reported
medications and
the medical
diagnosis for the
medication
(including name,

2 to >1.0 pts
Includes a list of
all of the patient
reported
medications and
the medical
diagnosis for
the medication
(including 3 of

1 to >0.0 pts
Includes a list
of all of the
patient
reported
medications
(including 2 of
the 4: name,

0 pts
Missing
criteria
and/or
submission
.

4
points

dose, route,
frequency)

the 4: name,
dose,
medications
route,
frequency)

dose, route,
frequency)

Past Medical
History

3 to >2.0 pts
Includes
(Major/Chronic,
Trauma,
Hospitalizations),
for each medical
diagnosis, year of
diagnosis and
whether the
diagnosis is active
or current

2 to >1.0 pts
Includes
(Major/Chronic,
Trauma,
Hospitalizations)
, for each
medical
diagnosis, either
year of
diagnosis OR
whether the
diagnosis is
active or current

1 to >0.0 pts
Includes each
medical
diagnosis but
does not
include year of
diagnosis or
whether the
diagnosis is
active or
current

0 pts
Missing
criteria
and/or
submission
.

3
points

Past Surgical
History

3 to >2.0 pts
Includes, for each
surgical procedure,
the year of
procedure and the
indication for the
procedure

2 to >1.0 pts
Includes, for
each surgical
procedure, the
year of
procedure OR
indication of the
procedure

1 to >0.0 pts
Includes, for
each surgical
procedure but
not the year of
procedure or
indication of
the procedure

0 pts
Missing
criteria
and/or
submission
.

3
points

Family History 3 to >2.0 pts
Includes an
assessment of at
least 4 family
members
regarding, at a
minimum, genetic
disorders, diabetes,
heart disease and
cancer.

2 to >1.0 pts
Includes an
assessment of
at least 3 family
members
regarding, at a
minimum,
genetic
disorders,
diabetes, heart
disease and
cancer.

1 to >0.0 pts
Includes an
assessment of
at least 2
family
members
regarding, at a
minimum,
genetic
disorders,
diabetes, heart
disease and
cancer.

0 pts
Missing
criteria
and/or
submission
.

3
points

Social History 3 to >2.0 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.

2 to >1.0 pts
Includes 10 of
the 11 required
following:
tobacco use,
drug use,
alcohol use,
marital status,
employment
status,
current/previous
occupation,
sexual
orientation,
sexually active,
contraceptive

1 to >0.0 pts
Includes 9 or
less of the
required
information.

0 pts
Missing
criteria
and/or
submission
.

3
points

use, and living
situation.

Health
Maintenance /
Screenings

3 to >2.0 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

2 to >1.0 pts
Includes a
partial
assessment of
immunization
status and
health
maintenance
needs, missing
some key
components.
Includes an
assessment of
at least 4
screening tests

1 to >0.0 pts
Includes
minimal
assessment of
immunization
status and
health
maintenance
needs, lacking
detail.
Includes an
assessment of
at least 3
screening
tests

0 pts
Missing
criteria
and/or
submission
.

3
points

Physical
Examination

15 to >8.0 pts
Includes a
minimum of 4
assessments for
each body system
and assesses at
least 5 body
systems directed to
chief complaint

8 to >3.0 pts
Includes a
minimum of 3
assessments for
each body
system and
assesses at
least 4 body
systems
directed to chief
complaint

3 to >0.0 pts
Includes a
minimum of 2
assessments
for each body
system and
assesses at
least 4 body
systems
directed to
chief
complaint

0 pts
Missing
criteria
and/or
submission
.

15
points

Diagnosis

5 to >3.0 pts
Includes a clear
outline of the
accurate principal
diagnosis AND lists
the remaining
diagnoses
addressed at the
visit (in descending
priority)

3 to >1.0 pts
Includes a clear
outline of the
accurate
diagnoses
addressed at the
visit but does
not list the
diagnoses in
descending
order of priority

1 to >0.0 pts
Includes 1
differential
diagnosis for
the principal
diagnosis

0 pts
Missing
criteria
and/or
submission
.

5
points

Differential
Diagnosis

5 to >3.0 pts
Includes at least 3
differential
diagnoses for the
principal diagnosis

3 to >1.0 pts
Includes at least
2 differential
diagnoses for
the principal
diagnosis

1 to >0.0 pts
Includes at
least 1
differential
diagnoses for
the principal
diagnosis

0 pts
Missing
criteria
and/or
submission
.

5
points

ICD 10 Coding 3 to >2.0 pts
Correctly includes
all ICD-10 codes
relevant to the
diagnoses
addressed at the
visit

2 to >1.0 pts
Correctly
includes most
ICD-10 codes
relevant to the
diagnoses
addressed at the
visit

1 to >0.0 pts
Includes some
ICD-10 codes
relevant to the
diagnoses
addressed at
the visit

0 pts
Missing
criteria
and/or
submission
.

3
points

Pharmacologi
c treatment
plan

5 to >3.0 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.

3 to >1.0 pts
Includes a
detailed
pharmacologic
treatment plan
for each of the
diagnoses listed
under
“assessment”.
The plan
includes 4 of the
required
following 7: the
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.

1 to >0.0 pts
Includes a
detailed
pharmacologi
c treatment
plan for each
of the
diagnoses
listed under
“assessment”.
The plan
includes less
than 4 of the
information:

0 pts
Missing
criteria
and/or
submission
.

5
points

Diagnostic /
Lab Testing

3 to >2.0 pts
Includes
appropriate
diagnostic/lab
testing 100% of the
time OR
acknowledges “no
diagnostic testing
clinically required
at this time”

2 to >1.0 pts
Includes
appropriate
diagnostic/lab
testing 50% of
the time OR
acknowledges
“no diagnostic
testing clinically
required at this
time”

1 to >0.0 pts
Includes
appropriate
diagnostic
testing less
than 50% of
the time.

0 pts
Missing
criteria
and/or
submission
.

3
points

Education 3 to >2.0 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.

2 to >1.0 pts
Includes at least
2 strategies to
promote and
develop skills
for managing
their illness and
at least 2 self-
management
methods on how
to incorporate
healthy
behaviors into
their lives.

1 to >0.0 pts
Includes at
least 1
strategies to
promote and
develop skills
for managing
their illness
and at least 1
self-
management
methods on
how to
incorporate

0 pts
Missing
criteria
and/or
submission
.

3
points

healthy
behaviors into
their lives

Anticipatory
Guidance

3 to >2.0 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))

2 to >1.0 pts
Includes at least
2 primary
prevention
strategies
(related to
age/condition
(i.e.
immunizations,
pediatric and
pre-natal
milestone
anticipator
guidance)) and
at least 2
secondary
prevention
strategies
(related to
age/condition
(i.e. screening))

1 to >0.0 pts
Includes at
least 1 primary
prevention
strategies
(related to
age/condition
(i.e.
immunizations
, pediatric and
pre-natal
milestone
anticipatory
guidance))
and at least 1
secondary
prevention
strategies
(related to
age/condition
(i.e.
screening))

0 pts
Missing
criteria
and/or
submission
.

3
points

Follow Up
Plan

2 to >1.0 pts
Includes
recommendation
for follow up,
including time
frame (i.e. x # of
days/weeks/months
)

1 to >0.0 pts
Includes recommendation for
follow up, but does not include
time frame (i.e. x # of
days/weeks/months)

0 pts
Missing
criteria
and/or
submission
.

2
points

Prescription 3 to >2.0 pts
Prescription
includes all
required
components:
patient information,
date, drug name,
dose, route,
frequency, quantity
to be dispensed,
refills, and
provider’s
signature and
credentials

2 to >1.0 pts
Prescription
includes most
required
components,
but is missing 1-
2 elements such
as quantity to be
dispensed or
refills

1 to >0.0 pts
Prescription is
missing 3 or
more required
components
such as
patient
information,
date, or
provider’s
signature

0 pts
Missing
criteria
and/or
submission
.

3
points

Writing
Mechanics,
Citations, and
APA Style

3 to >2.0 pts
Effectively uses the
literature and other
resources to inform
their work.
Exceptional use of
citations and
extended
referencing. APA

2 to >1.0 pts
Moderately use
the literature
and other
resources to
inform their
work.
Moderately use
of citations and

1 to >0.0 pts
Ineffectively
uses the
literature and
other
resources to
inform their
work.
Ineffectively

0 pts
Missing
criteria
and/or
submission
.

3
points

style is correct, and
writing is free of
grammar and
spelling errors.

extended
referencing. APA
style and writing
mechanics need
more precision
and attention to
detail.

use of
citations and
extended
referencing.
APA style and
writing
mechanics
need serious
attention.

Total 100

**## SOAPNoteTemplate.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])

**## SOAPNoteRubric1.pdf**

SOAP Note Rubric

Criteria Ratings Point
s

Demographics 1 to >0.8 pts
Begins with patient
initials, age, race,
ethnicity and
gender (5
demographics)

0.8 to >0.25 pts
Begins with 4 of
the 5 patient
demographics
(patient initials,
age, race,
ethnicity and
gender)

0.25 to
>0.0 pts
Begins with 3
or less patient
demographics
(patient
initials, age,
race, ethnicity
and gender)

0 pts
Missing
criteria
and/or
submission
.

1
point

Chief
Complaint
(Reason for
seeking health
care)

4 to >3.0 pts
Includes a direct
quote from patient
about presenting
problem

3 to >2.0 pts
Includes a direct
quote from
patient and
other unrelated
information

2 to >0.0 pts
Includes
information
but
information is
NOT a direct
quote

0 pts
Missing
criteria
and/or
submission
.

4
points

History of the
Present
Illness (HPI)

5 to >3.0 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)

3 to >2.0 pts
Includes the
presenting
problem and 7
of the 8
dimensions of
the problem
(OLD CARTS –
Onset, Location,
Duration,
Character,
Aggravating
factors,
Relieving
factors, Timing
and Severity)

2 to >0.0 pts
Includes the
presenting
problem and 6
of the 8
dimensions of
the problem
(OLD CARTS –
Onset,
Location,
Duration,
Character,
Aggravating
factors,
Relieving
factors,
Timing and
Severity)

0 pts
Missing
criteria
and/or
submission
.

5
points

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)

1.5 to >1.0 pts
If allergies are
present,
students lists
type Drug,
environmental
factor, herbal,
food, latex name
and includes
severity of
allergy OR
description of
allergy

1 to >0.0 pts
If allergies are
present,
students lists
only the type
of allergy
name

0 pts
Missing
criteria
and/or
submission
.

2
points

Review of
Systems
(ROS)

15 to >8.0 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”

8 to >3.0 pts
Includes 3 or
fewer
assessments for
each body
system and
assesses 5-8
body systems
directed to chief
complaint AND
uses the words
“admits” and
“denies”

3 to >0.0 pts
Includes 3 or
fewer
assessments
for each body
system and
assesses less
than 5 body
systems
directed to
chief
complaint OR
student does
not use the
words
“admits” and
“denies”

0 pts
Missing
criteria
and/or
submission
.

15
points

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.)

1.5 to >1.0 pts
Includes 7 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.)

1 to >0.0 pts
Includes 6 or
less vital
signs, (BP
(with patient
position), HR,
RR,
temperature
(with F or C
and route of
temperature
collection),
weight, height,
BMI (or
percentiles for
pediatric
population)
and pain.)

0 pts
Missing
criteria
and/or
submission
.

2
points

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.

1.5 to >1.0 pts
Includes a list of
the labs
reviewed at the
visit, values of
lab results but
does not
highlight
abnormal
values.

1 to >0.0 pts
Includes a list
of the labs
reviewed at
the visit but
does not
include the
values of lab
results or
highlight
abnormal
values.

0 pts
Missing
criteria
and/or
submission
.

2
points

Medications 4 to >2.0 pts
Includes a list of all
of the patient
reported
medications and
the medical
diagnosis for the
medication
(including name,

2 to >1.0 pts
Includes a list of
all of the patient
reported
medications and
the medical
diagnosis for
the medication
(including 3 of

1 to >0.0 pts
Includes a list
of all of the
patient
reported
medications
(including 2 of
the 4: name,

0 pts
Missing
criteria
and/or
submission
.

4
points

dose, route,
frequency)

the 4: name,
dose,
medications
route,
frequency)

dose, route,
frequency)

Past Medical
History

3 to >2.0 pts
Includes
(Major/Chronic,
Trauma,
Hospitalizations),
for each medical
diagnosis, year of
diagnosis and
whether the
diagnosis is active
or current

2 to >1.0 pts
Includes
(Major/Chronic,
Trauma,
Hospitalizations)
, for each
medical
diagnosis, either
year of
diagnosis OR
whether the
diagnosis is
active or current

1 to >0.0 pts
Includes each
medical
diagnosis but
does not
include year of
diagnosis or
whether the
diagnosis is
active or
current

0 pts
Missing
criteria
and/or
submission
.

3
points

Past Surgical
History

3 to >2.0 pts
Includes, for each
surgical procedure,
the year of
procedure and the
indication for the
procedure

2 to >1.0 pts
Includes, for
each surgical
procedure, the
year of
procedure OR
indication of the
procedure

1 to >0.0 pts
Includes, for
each surgical
procedure but
not the year of
procedure or
indication of
the procedure

0 pts
Missing
criteria
and/or
submission
.

3
points

Family History 3 to >2.0 pts
Includes an
assessment of at
least 4 family
members
regarding, at a
minimum, genetic
disorders, diabetes,
heart disease and
cancer.

2 to >1.0 pts
Includes an
assessment of
at least 3 family
members
regarding, at a
minimum,
genetic
disorders,
diabetes, heart
disease and
cancer.

1 to >0.0 pts
Includes an
assessment of
at least 2
family
members
regarding, at a
minimum,
genetic
disorders,
diabetes, heart
disease and
cancer.

0 pts
Missing
criteria
and/or
submission
.

3
points

Social History 3 to >2.0 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.

2 to >1.0 pts
Includes 10 of
the 11 required
following:
tobacco use,
drug use,
alcohol use,
marital status,
employment
status,
current/previous
occupation,
sexual
orientation,
sexually active,
contraceptive

1 to >0.0 pts
Includes 9 or
less of the
required
information.

0 pts
Missing
criteria
and/or
submission
.

3
points

use, and living
situation.

Health
Maintenance /
Screenings

3 to >2.0 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

2 to >1.0 pts
Includes a
partial
assessment of
immunization
status and
health
maintenance
needs, missing
some key
components.
Includes an
assessment of
at least 4
screening tests

1 to >0.0 pts
Includes
minimal
assessment of
immunization
status and
health
maintenance
needs, lacking
detail.
Includes an
assessment of
at least 3
screening
tests

0 pts
Missing
criteria
and/or
submission
.

3
points

Physical
Examination

15 to >8.0 pts
Includes a
minimum of 4
assessments for
each body system
and assesses at
least 5 body
systems directed to
chief complaint

8 to >3.0 pts
Includes a
minimum of 3
assessments for
each body
system and
assesses at
least 4 body
systems
directed to chief
complaint

3 to >0.0 pts
Includes a
minimum of 2
assessments
for each body
system and
assesses at
least 4 body
systems
directed to
chief
complaint

0 pts
Missing
criteria
and/or
submission
.

15
points

Diagnosis

5 to >3.0 pts
Includes a clear
outline of the
accurate principal
diagnosis AND lists
the remaining
diagnoses
addressed at the
visit (in descending
priority)

3 to >1.0 pts
Includes a clear
outline of the
accurate
diagnoses
addressed at the
visit but does
not list the
diagnoses in
descending
order of priority

1 to >0.0 pts
Includes 1
differential
diagnosis for
the principal
diagnosis

0 pts
Missing
criteria
and/or
submission
.

5
points

Differential
Diagnosis

5 to >3.0 pts
Includes at least 3
differential
diagnoses for the
principal diagnosis

3 to >1.0 pts
Includes at least
2 differential
diagnoses for
the principal
diagnosis

1 to >0.0 pts
Includes at
least 1
differential
diagnoses for
the principal
diagnosis

0 pts
Missing
criteria
and/or
submission
.

5
points

ICD 10 Coding 3 to >2.0 pts
Correctly includes
all ICD-10 codes
relevant to the
diagnoses
addressed at the
visit

2 to >1.0 pts
Correctly
includes most
ICD-10 codes
relevant to the
diagnoses
addressed at the
visit

1 to >0.0 pts
Includes some
ICD-10 codes
relevant to the
diagnoses
addressed at
the visit

0 pts
Missing
criteria
and/or
submission
.

3
points

Pharmacologi
c treatment
plan

5 to >3.0 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.

3 to >1.0 pts
Includes a
detailed
pharmacologic
treatment plan
for each of the
diagnoses listed
under
“assessment”.
The plan
includes 4 of the
required
following 7: the
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.

1 to >0.0 pts
Includes a
detailed
pharmacologi
c treatment
plan for each
of the
diagnoses
listed under
“assessment”.
The plan
includes less
than 4 of the
information:

0 pts
Missing
criteria
and/or
submission
.

5
points

Diagnostic /
Lab Testing

3 to >2.0 pts
Includes
appropriate
diagnostic/lab
testing 100% of the
time OR
acknowledges “no
diagnostic testing
clinically required
at this time”

2 to >1.0 pts
Includes
appropriate
diagnostic/lab
testing 50% of
the time OR
acknowledges
“no diagnostic
testing clinically
required at this
time”

1 to >0.0 pts
Includes
appropriate
diagnostic
testing less
than 50% of
the time.

0 pts
Missing
criteria
and/or
submission
.

3
points

Education 3 to >2.0 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.

2 to >1.0 pts
Includes at least
2 strategies to
promote and
develop skills
for managing
their illness and
at least 2 self-
management
methods on how
to incorporate
healthy
behaviors into
their lives.

1 to >0.0 pts
Includes at
least 1
strategies to
promote and
develop skills
for managing
their illness
and at least 1
self-
management
methods on
how to
incorporate

0 pts
Missing
criteria
and/or
submission
.

3
points

healthy
behaviors into
their lives

Anticipatory
Guidance

3 to >2.0 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))

2 to >1.0 pts
Includes at least
2 primary
prevention
strategies
(related to
age/condition
(i.e.
immunizations,
pediatric and
pre-natal
milestone
anticipator
guidance)) and
at least 2
secondary
prevention
strategies
(related to
age/condition
(i.e. screening))

1 to >0.0 pts
Includes at
least 1 primary
prevention
strategies
(related to
age/condition
(i.e.
immunizations
, pediatric and
pre-natal
milestone
anticipatory
guidance))
and at least 1
secondary
prevention
strategies
(related to
age/condition
(i.e.
screening))

0 pts
Missing
criteria
and/or
submission
.

3
points

Follow Up
Plan

2 to >1.0 pts
Includes
recommendation
for follow up,
including time
frame (i.e. x # of
days/weeks/months
)

1 to >0.0 pts
Includes recommendation for
follow up, but does not include
time frame (i.e. x # of
days/weeks/months)

0 pts
Missing
criteria
and/or
submission
.

2
points

Prescription 3 to >2.0 pts
Prescription
includes all
required
components:
patient information,
date, drug name,
dose, route,
frequency, quantity
to be dispensed,
refills, and
provider’s
signature and
credentials

2 to >1.0 pts
Prescription
includes most
required
components,
but is missing 1-
2 elements such
as quantity to be
dispensed or
refills

1 to >0.0 pts
Prescription is
missing 3 or
more required
components
such as
patient
information,
date, or
provider’s
signature

0 pts
Missing
criteria
and/or
submission
.

3
points

Writing
Mechanics,
Citations, and
APA Style

3 to >2.0 pts
Effectively uses the
literature and other
resources to inform
their work.
Exceptional use of
citations and
extended
referencing. APA

2 to >1.0 pts
Moderately use
the literature
and other
resources to
inform their
work.
Moderately use
of citations and

1 to >0.0 pts
Ineffectively
uses the
literature and
other
resources to
inform their
work.
Ineffectively

0 pts
Missing
criteria
and/or
submission
.

3
points

style is correct, and
writing is free of
grammar and
spelling errors.

extended
referencing. APA
style and writing
mechanics need
more precision
and attention to
detail.

use of
citations and
extended
referencing.
APA style and
writing
mechanics
need serious
attention.

Total 100

**## SOAPNoteTemplate.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])

**## SOAPNoteRubric1.pdf**

SOAP Note Rubric

Criteria Ratings Point
s

Demographics 1 to >0.8 pts
Begins with patient
initials, age, race,
ethnicity and
gender (5
demographics)

0.8 to >0.25 pts
Begins with 4 of
the 5 patient
demographics
(patient initials,
age, race,
ethnicity and
gender)

0.25 to
>0.0 pts
Begins with 3
or less patient
demographics
(patient
initials, age,
race, ethnicity
and gender)

0 pts
Missing
criteria
and/or
submission
.

1
point

Chief
Complaint
(Reason for
seeking health
care)

4 to >3.0 pts
Includes a direct
quote from patient
about presenting
problem

3 to >2.0 pts
Includes a direct
quote from
patient and
other unrelated
information

2 to >0.0 pts
Includes
information
but
information is
NOT a direct
quote

0 pts
Missing
criteria
and/or
submission
.

4
points

History of the
Present
Illness (HPI)

5 to >3.0 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)

3 to >2.0 pts
Includes the
presenting
problem and 7
of the 8
dimensions of
the problem
(OLD CARTS –
Onset, Location,
Duration,
Character,
Aggravating
factors,
Relieving
factors, Timing
and Severity)

2 to >0.0 pts
Includes the
presenting
problem and 6
of the 8
dimensions of
the problem
(OLD CARTS –
Onset,
Location,
Duration,
Character,
Aggravating
factors,
Relieving
factors,
Timing and
Severity)

0 pts
Missing
criteria
and/or
submission
.

5
points

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)

1.5 to >1.0 pts
If allergies are
present,
students lists
type Drug,
environmental
factor, herbal,
food, latex name
and includes
severity of
allergy OR
description of
allergy

1 to >0.0 pts
If allergies are
present,
students lists
only the type
of allergy
name

0 pts
Missing
criteria
and/or
submission
.

2
points

Review of
Systems
(ROS)

15 to >8.0 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”

8 to >3.0 pts
Includes 3 or
fewer
assessments for
each body
system and
assesses 5-8
body systems
directed to chief
complaint AND
uses the words
“admits” and
“denies”

3 to >0.0 pts
Includes 3 or
fewer
assessments
for each body
system and
assesses less
than 5 body
systems
directed to
chief
complaint OR
student does
not use the
words
“admits” and
“denies”

0 pts
Missing
criteria
and/or
submission
.

15
points

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.)

1.5 to >1.0 pts
Includes 7 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.)

1 to >0.0 pts
Includes 6 or
less vital
signs, (BP
(with patient
position), HR,
RR,
temperature
(with F or C
and route of
temperature
collection),
weight, height,
BMI (or
percentiles for
pediatric
population)
and pain.)

0 pts
Missing
criteria
and/or
submission
.

2
points

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.

1.5 to >1.0 pts
Includes a list of
the labs
reviewed at the
visit, values of
lab results but
does not
highlight
abnormal
values.

1 to >0.0 pts
Includes a list
of the labs
reviewed at
the visit but
does not
include the
values of lab
results or
highlight
abnormal
values.

0 pts
Missing
criteria
and/or
submission
.

2
points

Medications 4 to >2.0 pts
Includes a list of all
of the patient
reported
medications and
the medical
diagnosis for the
medication
(including name,

2 to >1.0 pts
Includes a list of
all of the patient
reported
medications and
the medical
diagnosis for
the medication
(including 3 of

1 to >0.0 pts
Includes a list
of all of the
patient
reported
medications
(including 2 of
the 4: name,

0 pts
Missing
criteria
and/or
submission
.

4
points

dose, route,
frequency)

the 4: name,
dose,
medications
route,
frequency)

dose, route,
frequency)

Past Medical
History

3 to >2.0 pts
Includes
(Major/Chronic,
Trauma,
Hospitalizations),
for each medical
diagnosis, year of
diagnosis and
whether the
diagnosis is active
or current

2 to >1.0 pts
Includes
(Major/Chronic,
Trauma,
Hospitalizations)
, for each
medical
diagnosis, either
year of
diagnosis OR
whether the
diagnosis is
active or current

1 to >0.0 pts
Includes each
medical
diagnosis but
does not
include year of
diagnosis or
whether the
diagnosis is
active or
current

0 pts
Missing
criteria
and/or
submission
.

3
points

Past Surgical
History

3 to >2.0 pts
Includes, for each
surgical procedure,
the year of
procedure and the
indication for the
procedure

2 to >1.0 pts
Includes, for
each surgical
procedure, the
year of
procedure OR
indication of the
procedure

1 to >0.0 pts
Includes, for
each surgical
procedure but
not the year of
procedure or
indication of
the procedure

0 pts
Missing
criteria
and/or
submission
.

3
points

Family History 3 to >2.0 pts
Includes an
assessment of at
least 4 family
members
regarding, at a
minimum, genetic
disorders, diabetes,
heart disease and
cancer.

2 to >1.0 pts
Includes an
assessment of
at least 3 family
members
regarding, at a
minimum,
genetic
disorders,
diabetes, heart
disease and
cancer.

1 to >0.0 pts
Includes an
assessment of
at least 2
family
members
regarding, at a
minimum,
genetic
disorders,
diabetes, heart
disease and
cancer.

0 pts
Missing
criteria
and/or
submission
.

3
points

Social History 3 to >2.0 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.

2 to >1.0 pts
Includes 10 of
the 11 required
following:
tobacco use,
drug use,
alcohol use,
marital status,
employment
status,
current/previous
occupation,
sexual
orientation,
sexually active,
contraceptive

1 to >0.0 pts
Includes 9 or
less of the
required
information.

0 pts
Missing
criteria
and/or
submission
.

3
points

use, and living
situation.

Health
Maintenance /
Screenings

3 to >2.0 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

2 to >1.0 pts
Includes a
partial
assessment of
immunization
status and
health
maintenance
needs, missing
some key
components.
Includes an
assessment of
at least 4
screening tests

1 to >0.0 pts
Includes
minimal
assessment of
immunization
status and
health
maintenance
needs, lacking
detail.
Includes an
assessment of
at least 3
screening
tests

0 pts
Missing
criteria
and/or
submission
.

3
points

Physical
Examination

15 to >8.0 pts
Includes a
minimum of 4
assessments for
each body system
and assesses at
least 5 body
systems directed to
chief complaint

8 to >3.0 pts
Includes a
minimum of 3
assessments for
each body
system and
assesses at
least 4 body
systems
directed to chief
complaint

3 to >0.0 pts
Includes a
minimum of 2
assessments
for each body
system and
assesses at
least 4 body
systems
directed to
chief
complaint

0 pts
Missing
criteria
and/or
submission
.

15
points

Diagnosis

5 to >3.0 pts
Includes a clear
outline of the
accurate principal
diagnosis AND lists
the remaining
diagnoses
addressed at the
visit (in descending
priority)

3 to >1.0 pts
Includes a clear
outline of the
accurate
diagnoses
addressed at the
visit but does
not list the
diagnoses in
descending
order of priority

1 to >0.0 pts
Includes 1
differential
diagnosis for
the principal
diagnosis

0 pts
Missing
criteria
and/or
submission
.

5
points

Differential
Diagnosis

5 to >3.0 pts
Includes at least 3
differential
diagnoses for the
principal diagnosis

3 to >1.0 pts
Includes at least
2 differential
diagnoses for
the principal
diagnosis

1 to >0.0 pts
Includes at
least 1
differential
diagnoses for
the principal
diagnosis

0 pts
Missing
criteria
and/or
submission
.

5
points

ICD 10 Coding 3 to >2.0 pts
Correctly includes
all ICD-10 codes
relevant to the
diagnoses
addressed at the
visit

2 to >1.0 pts
Correctly
includes most
ICD-10 codes
relevant to the
diagnoses
addressed at the
visit

1 to >0.0 pts
Includes some
ICD-10 codes
relevant to the
diagnoses
addressed at
the visit

0 pts
Missing
criteria
and/or
submission
.

3
points

Pharmacologi
c treatment
plan

5 to >3.0 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.

3 to >1.0 pts
Includes a
detailed
pharmacologic
treatment plan
for each of the
diagnoses listed
under
“assessment”.
The plan
includes 4 of the
required
following 7: the
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.

1 to >0.0 pts
Includes a
detailed
pharmacologi
c treatment
plan for each
of the
diagnoses
listed under
“assessment”.
The plan
includes less
than 4 of the
information:

0 pts
Missing
criteria
and/or
submission
.

5
points

Diagnostic /
Lab Testing

3 to >2.0 pts
Includes
appropriate
diagnostic/lab
testing 100% of the
time OR
acknowledges “no
diagnostic testing
clinically required
at this time”

2 to >1.0 pts
Includes
appropriate
diagnostic/lab
testing 50% of
the time OR
acknowledges
“no diagnostic
testing clinically
required at this
time”

1 to >0.0 pts
Includes
appropriate
diagnostic
testing less
than 50% of
the time.

0 pts
Missing
criteria
and/or
submission
.

3
points

Education 3 to >2.0 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.

2 to >1.0 pts
Includes at least
2 strategies to
promote and
develop skills
for managing
their illness and
at least 2 self-
management
methods on how
to incorporate
healthy
behaviors into
their lives.

1 to >0.0 pts
Includes at
least 1
strategies to
promote and
develop skills
for managing
their illness
and at least 1
self-
management
methods on
how to
incorporate

0 pts
Missing
criteria
and/or
submission
.

3
points

healthy
behaviors into
their lives

Anticipatory
Guidance

3 to >2.0 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))

2 to >1.0 pts
Includes at least
2 primary
prevention
strategies
(related to
age/condition
(i.e.
immunizations,
pediatric and
pre-natal
milestone
anticipator
guidance)) and
at least 2
secondary
prevention
strategies
(related to
age/condition
(i.e. screening))

1 to >0.0 pts
Includes at
least 1 primary
prevention
strategies
(related to
age/condition
(i.e.
immunizations
, pediatric and
pre-natal
milestone
anticipatory
guidance))
and at least 1
secondary
prevention
strategies
(related to
age/condition
(i.e.
screening))

0 pts
Missing
criteria
and/or
submission
.

3
points

Follow Up
Plan

2 to >1.0 pts
Includes
recommendation
for follow up,
including time
frame (i.e. x # of
days/weeks/months
)

1 to >0.0 pts
Includes recommendation for
follow up, but does not include
time frame (i.e. x # of
days/weeks/months)

0 pts
Missing
criteria
and/or
submission
.

2
points

Prescription 3 to >2.0 pts
Prescription
includes all
required
components:
patient information,
date, drug name,
dose, route,
frequency, quantity
to be dispensed,
refills, and
provider’s
signature and
credentials

2 to >1.0 pts
Prescription
includes most
required
components,
but is missing 1-
2 elements such
as quantity to be
dispensed or
refills

1 to >0.0 pts
Prescription is
missing 3 or
more required
components
such as
patient
information,
date, or
provider’s
signature

0 pts
Missing
criteria
and/or
submission
.

3
points

Writing
Mechanics,
Citations, and
APA Style

3 to >2.0 pts
Effectively uses the
literature and other
resources to inform
their work.
Exceptional use of
citations and
extended
referencing. APA

2 to >1.0 pts
Moderately use
the literature
and other
resources to
inform their
work.
Moderately use
of citations and

1 to >0.0 pts
Ineffectively
uses the
literature and
other
resources to
inform their
work.
Ineffectively

0 pts
Missing
criteria
and/or
submission
.

3
points

style is correct, and
writing is free of
grammar and
spelling errors.

extended
referencing. APA
style and writing
mechanics need
more precision
and attention to
detail.

use of
citations and
extended
referencing.
APA style and
writing
mechanics
need serious
attention.

Total 100

– 1
– 2

November 5, 2026
[Solved] L6

✓ Verified Academic Solution Available

Executive Solution Overview

Identify 3 aspects of U.S. foreign policy present during this time (the 1930’s through 1950’s). Discuss how these different approaches influence U.S. foreign policy. Additionally, discuss how events or policies during this time have influenced policies today.

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Assignment Prompt & Instructions

Identify 3 aspects of U.S. foreign policy present during this time (the 1930’s through 1950’s). Discuss how these different approaches influence U.S. foreign policy. Additionally, discuss how events or policies during this time have influenced policies today.

November 5, 2026
[Solved] Psychology

✓ Verified Academic Solution Available

Executive Solution Overview

Think about a question or curiosity you have about human behavior or mental processes. It could be something you've always wondered about, such as why people procrastinate, how memory works, or what influences decision-making. Share your question or curiosity with the class and explain why it intere…

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Think about a question or curiosity you have about human behavior or mental processes. It could be something you've always wondered about, such as why people procrastinate, how memory works, or what influences decision-making. Share your question or curiosity with the class and explain why it interests you.
Next, utilize the scientific method outlined in Chapter 2 to investigate your inquiry by **crafting a hypothesis**—a conjecture that can be tested—pertaining to your question.
Lastly, engage with at least two classmates' posts by offering your insights on the most suitable method of data collection to test their hypotheses. Consider whether naturalistic observation, a case study, a survey, or the experimental method would be most appropriate, and **explain your reasoning behind your choice**. Consider factors such as the research question, the variables involved, and the feasibility of each method in addressing their hypotheses effectively.
Attach is Chapter 2 from the book
\
Chapter2ResearchinPsychology0.pdf](https://www.sweetstudy.com/files/chapter2researchinpsychology0-pdf "Chapter2ResearchinPsychology0.pdf")

November 5, 2026
[Solved] NU505-4

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In-depth study guidance and analytical solution covering NU505-4.

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Full assignment prompt and step-by-step guidance are included in the downloadable solution file.

November 5, 2026
[Solved] What is a study in Aba ?

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Can you help create a study in Aba ?

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Can you help create a study in Aba ?

November 5, 2026
[Solved] s hinton week 2

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Darr writes, " To transform the organization so that its culture is a living reflection of values that facilitate the mission and vision, management must know what values are present in the culture" . Create a hypothetical organizational philosophy statement. Include a mission statement, vision stat…

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Darr writes, " To transform the organization so that its culture is a living reflection of values that facilitate the mission and vision, management must know what values are present in the culture" .
Create a hypothetical organizational philosophy statement. Include a mission statement, vision statement, and core principles/values.
Reference:
Darr, K. (2011). Ethics in Health Services Management. (5th Edition). Baltimore, MD: Health Professions Press, Inc.

November 5, 2026
[Solved] case study class 502

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November 5, 2026
[Solved] jameire

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Begin by selecting an individual elite level athlete. This athlete will be the focus on your final project and they will be used throughout the course in discussions. This athlete must participate in a sport or event where a minimum of 2 dynamic movements take place. For example: A 100m sprinter doe…

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Begin by selecting an individual elite level athlete.
            This athlete will be the focus on your final project and they will be used throughout the course in discussions.
            This athlete must participate in a sport or event where a minimum of 2 dynamic movements take place.
                         For example: A 100m sprinter does not use multiple dynamic skills during his/her sprint. In contrast, a tennis player uses skills such as serving and a back hand shot during their game.
                         Another example: A marathon runner does not use multiple dynamic skills during his/her run. In contrast a triathlete must bike, run, and swim, using 3 dynamic skills during competition.
I would even argue not to use an MLB pitcher, unless they play for the National League, nor use a softball pitcher, as they have a DH rule in place at every level of Elite International play. Possibly, use a softball or baseball infielder or outfielder as they are required to field, throw, hit, and run which is more than 3 skills.
You may **NOT** choose an Olympic weightlifting athlete. These lifts have been over analyzed and will not provide a deeper understanding of the dynamic movements of the human body.
A great place to search for an athlete who uses more than 2 dynamic skills during competition is the [https://www.olympicchannel.com/en/sports/](https://www.olympicchannel.com/en/sports/)   Olympic Channel All sports list. From there, find an athlete that participates in the sport you are interested in.
To assist you in your final project, specifically data collection and analysis, be sure your chosen athlete has multiple photos, videos, interviews, etc of them performing fundamental skills within in their sport. If the athlete has instructional videos, books, articles, etc, they would be a great choice, as they will assist you with your analysis process.
**Assignment 1 Instructions:**
**Part 1.**
In a word document provide the following…
– Name of athlete, followed by an introduction, explaining their situation, environment, movements, and why you chose this athlete, including the following identifiers:
Gender
– Age
– Home/Competition Country
– Sport
– Level of competition
– Position(s)
– Dynamic skills involved in the fundamental aspects of their position(s)
**Part 2.**
Using the information from week two, identify primary skeletal and muscular involvement in your subject’s movement. Consider your week eight analysis, what are the prime movers and supporting skeletal structure required to perform?

November 5, 2026
[Solved] C4

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your own personal experience in a discipling/coaching/mentoring situation,

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your own personal experience in a discipling/coaching/mentoring situation,

November 5, 2026
[Solved] nursing judjement outcome

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– ## ReflectionPaperTemplate1.docx – ## ReflectionPaperTemplate11.docx – ## PsychosocialNursingReflectionPaperAssignment1.docx **## ReflectionPaperTemplate1.docx** Reflection Paper Psychosocial 2400 | | | — | | Introduction and Nursing Diagnoses: | | | | — | | Reflection: | | | | — | | Nursing…

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Assignment Prompt & Instructions

– ## ReflectionPaperTemplate1.docx

– ## ReflectionPaperTemplate11.docx

– ## PsychosocialNursingReflectionPaperAssignment1.docx

**## ReflectionPaperTemplate1.docx**

Reflection Paper

Psychosocial 2400

| |
| — |
| Introduction and Nursing Diagnoses: |

| |
| — |
| Reflection: |

| |
| — |
| Nursing Care Plan: |

| | |
| — | — |
| Nursing Intervention | Rationale & Evaluations |
| | |
| | |
| | |

**Reference page is a separate**

**## ReflectionPaperTemplate11.docx**

Reflection Paper

Psychosocial 2400

| |
| — |
| Introduction and Nursing Diagnoses: |

| |
| — |
| Reflection: |

| |
| — |
| Nursing Care Plan: |

| | |
| — | — |
| Nursing Intervention | Rationale & Evaluations |
| | |
| | |
| | |

**Reference page is a separate**

**## PsychosocialNursingReflectionPaperAssignment1.docx**

**Psychosocial Nursing Reflection Paper Assignment**

Objectives

1. Consider future nursing opportunities in relation to clinical findings, including current issues in mental health care and potential applications for advocacy and support related to clients with mental health diagnoses and their families.
_(Human Flourishing)_

Assignment

Write a 500-word reflection paper based on the information you gathered at your mental health rotation OR with a Med/Surg, etc. patient, OR the movie (options listed in D2L and only if you haven’t had your mental health rotation/Med/Surg pt).

**Introduction and Nursing Diagnoses**

Include basic client information (without identifiers) and psychiatric diagnosis/diagnoses as well as pertinent physical diagnoses.

Relay your top two priority nursing diagnoses (from your clinical observation sheet) and briefly discuss your rationale for these. Ideally, you will have one 3-Part and one “Risk For”. Diagnoses are often appropriate in mental health patients but must exclude evidence. If there’s evidence then it happened, and it’s no longer a “risk for” because it really exists. Nursing diagnoses must be formatted correctly, whether they have 2 (risk for) or 3 parts. Rationale should include observations, quotations, reports from staff or family, or other sources that led you to choose these diagnoses. This section should take up approximately half a page or 125 words.

**Reflection**

Based on the diagnoses identified, use the next page (around 250 words) to reflect on your ideas of how to provide the best care for this client and their family. Consider whether you think they are currently receiving the best possible care and what other supports and resources might better help them. Consider the following questions:

What are the barriers to implementing the nursing interventions you listed in your clinical assignment?

What ethical principles apply to these considerations?

What resources are available in your community for this patient and/or their family?

*Chapters 34-36 in your textbook provide information about group and family therapy as well as integrative treatment options that might support your discussion.

Considerations

Ethical Principles

1. Autonomy- Respecting the rights of others to make their own decisions.

2. Beneficence- The duty to act to benefit or promote the health and well-being of others.

3. Nonmaleficence- Doing no harm to the patient

4. Justice- The duty to distribute resources or care equally, regardless of personal attributes

5. Fidelity- Maintaining loyalty and commitment to the patient and doing no wrong to the patient

6. Veracity- The duty to communicate truthfully

Varcarolis’ page 93 (9th edition)

[https://nurse.org/education/nursing-code-of-ethics/](https://nurse.org/education/nursing-code-of-ethics/)

Patients’ rights are discussed on page 96 in the 9th edition.

**Nursing Care Plan**

Take approximately the final half page (125 words) to create a nursing care plan for your client. Choose the primary nursing diagnosis of the two you gave at the beginning of the paper and provide a brief rationale for your choice. State one (or two) relevant goals for your care plan and the method of evaluation you will use to determine the effectiveness of your plan. Use the table (SEE TEMPLATE) to fill in your proposed interventions and rationales. See the site below for examples.

[https://nurseslabs.com/category/nursing-care-plans/mental-health-psychiatric/](https://nurseslabs.com/category/nursing-care-plans/mental-health-psychiatric/)

**References**

This is on its own page. Perfection will not make or break you. Just make an effort at the rules. If you go on in your nursing education, which I hope you do, this will be something you have to know. We’ll start slowly in this program. Two or three references are fine, and your textbook can be one of them. The rules are here:
[https://owl.purdue.edu/owl/research_and_citation/apa_style/apa_formatting_and_style_guide/reference_list_basic_rules.html](https://owl.purdue.edu/owl/research_and_citation/apa_style/apa_formatting_and_style_guide/reference_list_basic_rules.html)

**## PsychosocialNursingReflectionPaperAssignment1.docx**

**Psychosocial Nursing Reflection Paper Assignment**

Objectives

1. Consider future nursing opportunities in relation to clinical findings, including current issues in mental health care and potential applications for advocacy and support related to clients with mental health diagnoses and their families.
_(Human Flourishing)_

Assignment

Write a 500-word reflection paper based on the information you gathered at your mental health rotation OR with a Med/Surg, etc. patient, OR the movie (options listed in D2L and only if you haven’t had your mental health rotation/Med/Surg pt).

**Introduction and Nursing Diagnoses**

Include basic client information (without identifiers) and psychiatric diagnosis/diagnoses as well as pertinent physical diagnoses.

Relay your top two priority nursing diagnoses (from your clinical observation sheet) and briefly discuss your rationale for these. Ideally, you will have one 3-Part and one “Risk For”. Diagnoses are often appropriate in mental health patients but must exclude evidence. If there’s evidence then it happened, and it’s no longer a “risk for” because it really exists. Nursing diagnoses must be formatted correctly, whether they have 2 (risk for) or 3 parts. Rationale should include observations, quotations, reports from staff or family, or other sources that led you to choose these diagnoses. This section should take up approximately half a page or 125 words.

**Reflection**

Based on the diagnoses identified, use the next page (around 250 words) to reflect on your ideas of how to provide the best care for this client and their family. Consider whether you think they are currently receiving the best possible care and what other supports and resources might better help them. Consider the following questions:

What are the barriers to implementing the nursing interventions you listed in your clinical assignment?

What ethical principles apply to these considerations?

What resources are available in your community for this patient and/or their family?

*Chapters 34-36 in your textbook provide information about group and family therapy as well as integrative treatment options that might support your discussion.

Considerations

Ethical Principles

1. Autonomy- Respecting the rights of others to make their own decisions.

2. Beneficence- The duty to act to benefit or promote the health and well-being of others.

3. Nonmaleficence- Doing no harm to the patient

4. Justice- The duty to distribute resources or care equally, regardless of personal attributes

5. Fidelity- Maintaining loyalty and commitment to the patient and doing no wrong to the patient

6. Veracity- The duty to communicate truthfully

Varcarolis’ page 93 (9th edition)

[https://nurse.org/education/nursing-code-of-ethics/](https://nurse.org/education/nursing-code-of-ethics/)

Patients’ rights are discussed on page 96 in the 9th edition.

**Nursing Care Plan**

Take approximately the final half page (125 words) to create a nursing care plan for your client. Choose the primary nursing diagnosis of the two you gave at the beginning of the paper and provide a brief rationale for your choice. State one (or two) relevant goals for your care plan and the method of evaluation you will use to determine the effectiveness of your plan. Use the table (SEE TEMPLATE) to fill in your proposed interventions and rationales. See the site below for examples.

[https://nurseslabs.com/category/nursing-care-plans/mental-health-psychiatric/](https://nurseslabs.com/category/nursing-care-plans/mental-health-psychiatric/)

**References**

This is on its own page. Perfection will not make or break you. Just make an effort at the rules. If you go on in your nursing education, which I hope you do, this will be something you have to know. We’ll start slowly in this program. Two or three references are fine, and your textbook can be one of them. The rules are here:
[https://owl.purdue.edu/owl/research_and_citation/apa_style/apa_formatting_and_style_guide/reference_list_basic_rules.html](https://owl.purdue.edu/owl/research_and_citation/apa_style/apa_formatting_and_style_guide/reference_list_basic_rules.html)

**## ReflectionPaperTemplate1.docx**

Reflection Paper

Psychosocial 2400

| |
| — |
| Introduction and Nursing Diagnoses: |

| |
| — |
| Reflection: |

| |
| — |
| Nursing Care Plan: |

| | |
| — | — |
| Nursing Intervention | Rationale & Evaluations |
| | |
| | |
| | |

**Reference page is a separate**

**## ReflectionPaperTemplate11.docx**

Reflection Paper

Psychosocial 2400

| |
| — |
| Introduction and Nursing Diagnoses: |

| |
| — |
| Reflection: |

| |
| — |
| Nursing Care Plan: |

| | |
| — | — |
| Nursing Intervention | Rationale & Evaluations |
| | |
| | |
| | |

**Reference page is a separate**

**## PsychosocialNursingReflectionPaperAssignment1.docx**

**Psychosocial Nursing Reflection Paper Assignment**

Objectives

1. Consider future nursing opportunities in relation to clinical findings, including current issues in mental health care and potential applications for advocacy and support related to clients with mental health diagnoses and their families.
_(Human Flourishing)_

Assignment

Write a 500-word reflection paper based on the information you gathered at your mental health rotation OR with a Med/Surg, etc. patient, OR the movie (options listed in D2L and only if you haven’t had your mental health rotation/Med/Surg pt).

**Introduction and Nursing Diagnoses**

Include basic client information (without identifiers) and psychiatric diagnosis/diagnoses as well as pertinent physical diagnoses.

Relay your top two priority nursing diagnoses (from your clinical observation sheet) and briefly discuss your rationale for these. Ideally, you will have one 3-Part and one “Risk For”. Diagnoses are often appropriate in mental health patients but must exclude evidence. If there’s evidence then it happened, and it’s no longer a “risk for” because it really exists. Nursing diagnoses must be formatted correctly, whether they have 2 (risk for) or 3 parts. Rationale should include observations, quotations, reports from staff or family, or other sources that led you to choose these diagnoses. This section should take up approximately half a page or 125 words.

**Reflection**

Based on the diagnoses identified, use the next page (around 250 words) to reflect on your ideas of how to provide the best care for this client and their family. Consider whether you think they are currently receiving the best possible care and what other supports and resources might better help them. Consider the following questions:

What are the barriers to implementing the nursing interventions you listed in your clinical assignment?

What ethical principles apply to these considerations?

What resources are available in your community for this patient and/or their family?

*Chapters 34-36 in your textbook provide information about group and family therapy as well as integrative treatment options that might support your discussion.

Considerations

Ethical Principles

1. Autonomy- Respecting the rights of others to make their own decisions.

2. Beneficence- The duty to act to benefit or promote the health and well-being of others.

3. Nonmaleficence- Doing no harm to the patient

4. Justice- The duty to distribute resources or care equally, regardless of personal attributes

5. Fidelity- Maintaining loyalty and commitment to the patient and doing no wrong to the patient

6. Veracity- The duty to communicate truthfully

Varcarolis’ page 93 (9th edition)

[https://nurse.org/education/nursing-code-of-ethics/](https://nurse.org/education/nursing-code-of-ethics/)

Patients’ rights are discussed on page 96 in the 9th edition.

**Nursing Care Plan**

Take approximately the final half page (125 words) to create a nursing care plan for your client. Choose the primary nursing diagnosis of the two you gave at the beginning of the paper and provide a brief rationale for your choice. State one (or two) relevant goals for your care plan and the method of evaluation you will use to determine the effectiveness of your plan. Use the table (SEE TEMPLATE) to fill in your proposed interventions and rationales. See the site below for examples.

[https://nurseslabs.com/category/nursing-care-plans/mental-health-psychiatric/](https://nurseslabs.com/category/nursing-care-plans/mental-health-psychiatric/)

**References**

This is on its own page. Perfection will not make or break you. Just make an effort at the rules. If you go on in your nursing education, which I hope you do, this will be something you have to know. We’ll start slowly in this program. Two or three references are fine, and your textbook can be one of them. The rules are here:
[https://owl.purdue.edu/owl/research_and_citation/apa_style/apa_formatting_and_style_guide/reference_list_basic_rules.html](https://owl.purdue.edu/owl/research_and_citation/apa_style/apa_formatting_and_style_guide/reference_list_basic_rules.html)

**## ReflectionPaperTemplate1.docx**

Reflection Paper

Psychosocial 2400

| |
| — |
| Introduction and Nursing Diagnoses: |

| |
| — |
| Reflection: |

| |
| — |
| Nursing Care Plan: |

| | |
| — | — |
| Nursing Intervention | Rationale & Evaluations |
| | |
| | |
| | |

**Reference page is a separate**

**## ReflectionPaperTemplate11.docx**

Reflection Paper

Psychosocial 2400

| |
| — |
| Introduction and Nursing Diagnoses: |

| |
| — |
| Reflection: |

| |
| — |
| Nursing Care Plan: |

| | |
| — | — |
| Nursing Intervention | Rationale & Evaluations |
| | |
| | |
| | |

**Reference page is a separate**

**## PsychosocialNursingReflectionPaperAssignment1.docx**

**Psychosocial Nursing Reflection Paper Assignment**

Objectives

1. Consider future nursing opportunities in relation to clinical findings, including current issues in mental health care and potential applications for advocacy and support related to clients with mental health diagnoses and their families.
_(Human Flourishing)_

Assignment

Write a 500-word reflection paper based on the information you gathered at your mental health rotation OR with a Med/Surg, etc. patient, OR the movie (options listed in D2L and only if you haven’t had your mental health rotation/Med/Surg pt).

**Introduction and Nursing Diagnoses**

Include basic client information (without identifiers) and psychiatric diagnosis/diagnoses as well as pertinent physical diagnoses.

Relay your top two priority nursing diagnoses (from your clinical observation sheet) and briefly discuss your rationale for these. Ideally, you will have one 3-Part and one “Risk For”. Diagnoses are often appropriate in mental health patients but must exclude evidence. If there’s evidence then it happened, and it’s no longer a “risk for” because it really exists. Nursing diagnoses must be formatted correctly, whether they have 2 (risk for) or 3 parts. Rationale should include observations, quotations, reports from staff or family, or other sources that led you to choose these diagnoses. This section should take up approximately half a page or 125 words.

**Reflection**

Based on the diagnoses identified, use the next page (around 250 words) to reflect on your ideas of how to provide the best care for this client and their family. Consider whether you think they are currently receiving the best possible care and what other supports and resources might better help them. Consider the following questions:

What are the barriers to implementing the nursing interventions you listed in your clinical assignment?

What ethical principles apply to these considerations?

What resources are available in your community for this patient and/or their family?

*Chapters 34-36 in your textbook provide information about group and family therapy as well as integrative treatment options that might support your discussion.

Considerations

Ethical Principles

1. Autonomy- Respecting the rights of others to make their own decisions.

2. Beneficence- The duty to act to benefit or promote the health and well-being of others.

3. Nonmaleficence- Doing no harm to the patient

4. Justice- The duty to distribute resources or care equally, regardless of personal attributes

5. Fidelity- Maintaining loyalty and commitment to the patient and doing no wrong to the patient

6. Veracity- The duty to communicate truthfully

Varcarolis’ page 93 (9th edition)

[https://nurse.org/education/nursing-code-of-ethics/](https://nurse.org/education/nursing-code-of-ethics/)

Patients’ rights are discussed on page 96 in the 9th edition.

**Nursing Care Plan**

Take approximately the final half page (125 words) to create a nursing care plan for your client. Choose the primary nursing diagnosis of the two you gave at the beginning of the paper and provide a brief rationale for your choice. State one (or two) relevant goals for your care plan and the method of evaluation you will use to determine the effectiveness of your plan. Use the table (SEE TEMPLATE) to fill in your proposed interventions and rationales. See the site below for examples.

[https://nurseslabs.com/category/nursing-care-plans/mental-health-psychiatric/](https://nurseslabs.com/category/nursing-care-plans/mental-health-psychiatric/)

**References**

This is on its own page. Perfection will not make or break you. Just make an effort at the rules. If you go on in your nursing education, which I hope you do, this will be something you have to know. We’ll start slowly in this program. Two or three references are fine, and your textbook can be one of them. The rules are here:
[https://owl.purdue.edu/owl/research_and_citation/apa_style/apa_formatting_and_style_guide/reference_list_basic_rules.html](https://owl.purdue.edu/owl/research_and_citation/apa_style/apa_formatting_and_style_guide/reference_list_basic_rules.html)

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November 5, 2026