Discussion: Patient’s Chief Complaint (CC).

Distinguised Excellent Fair Poor Includes a direct quote from patient about presenting problem Includes a direct quote from patient and other unrelated information Includes information but information is NOT a direct quote Information is completely missing 4 Points Begins with patient initials, age, race, ethnicity and gender (5 demographics) 3 Points Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity and gender) 2 Points Begins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender) Information is completely missing 2 Points 1.5 Points 1 Points 0 Points Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) 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) 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) Information is completely missing 5 Points 3 Points 2 Points 0 Points If allergies are present, students lists only the type of allergy name Information is completely missing 1 Points 0 Points Subjective Chief Complaint (Reason for seeking health care) Demographics History of the Present Illness (HPI) Allergies Includes NKA (including = Drug, If allergies are present, students lists type Drug, Environemental, Food, Herbal, and/or Latex environemtal factor, herbal, food, latex name and or if allergies are present (reports for each includes severity of allergy OR description of severity of allergy AND description of allergy allergy) 2 Points Review of Systems (ROS) 1.5 Points Includes 3 or fewer assessments for each body Includes 3 or fewer assessments for each body Includes a minimum of 3 assessments for each body system and assesses at least 9 system and assesses 5-8 body systems directed to system and assesses less than 5 body systems chief complaint AND uses the words “admits” directed to chief complaint OR student does not body systems directed to chief complaint use the words “admits” and “denies” and “denies” AND uses the words “admits” and “denies” 12 Points 6 Points 3 Points 0 Points Information is completely missing 0 Points Objective Vital Signs Includes all 8 vital signs, (BP (with patient Includes 7 vital signs, (BP (with patient position), Discussion: Patient’s Chief Complaint (CC).

Includes 6 or less vital signs, (BP (with patient position), HR, RR, temperature (with HR, RR, temperature (with Fahrenheit or Celsius position), HR, RR, temperature (with Fahrenheit Fahrenheit or Celsius and route of and route of temperature collection), weight, or Celsius and route of temperature collection), Information is completely missing temperature collection), weight, height, BMI height, BMI (or percentiles for pediatric weight, height, BMI (or percentiles for pediatric (or percentiles for pediatric population) and population) and pain.) population) and pain.) pain.) 2 Points Labs Medications 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. 3 Points Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency) 1.5 Points Includes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal values. 1 Points 0 Points Includes a list of the labs reviewed at the visit but does not include the values of lab results or Information is completely missing highlight abnormal values. 2 Points 1 Points Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including 3 of the 4: name, dose, medications route, frequency) Includes a list of all of the patient reported medications (including 2 of the 4: name, dose, route, frequency) 0 Points Information is completely missing Screenings Past Medical History 4 Points Includes an assessment of at least 5 screening tests 2 Points Includes an assessment of at least 4 screening tests 3 Points 2 Points Includes (Major/Chronic, Trauma, Includes (Major/Chronic, Trauma, Hospitaliztions), for each medical diagnosis, Hospitaliztions), for each medical diagnosis, year of diagnosis and whether the diagnosis either year of diagnosis OR whether the diagnosis is active or current is active or current 3 Points Past Surgical History Family History Social History 0 Points Information is completely missing 1 Points 0 Points Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current Information is completely missing 1 Points 0 Points Includes, for each surgical procedure, the Includes, for each surgical procedure, the year of Includes, for each surgical procedure but not the year of procedure and the indication for the procedure OR indication of the procedure year of procedure or indication of the procedure Information is completely missing procedure 3 Points Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer. 3 Points Includes all of the following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation. 3 Points Physical Examination 2 Points 1 Points Includes an assessment of at least 3 screening tests Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint 12 Points 2 Points 1 Points 0 Points Includes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer. Discussion: Patient’s Chief Complaint (CC).

Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer. Information is completely missing 2 Points 1 Points 0 Points Includes 10 of the 11 following: tobacco use, Includes 9 or less of the following: tobacco use, drug use, alcohol use, marital status, employment drug use, alcohol use, marital status, employment status, current/previous occupation, sexual status, current/previous occupation, sexual Information is completely missing orientation, sexually active, contraceptive use, orientation, sexually active, contraceptive use, and living situation. and living situation. 2 Points 1 Points 0 Points Includes a minimum of 3 assessments for each Includes a minimum of 2 assessments for each body system and assesses at least 4 body systems body system and assesses at least 4 body systems Information is completely missing directed to chief complaint directed to chief complaint 6 Points 3 Points 0 Points Assessment Diagnosis Includes a clear outline of the accurate Includes a clear outline of the accurate diagnoses principal diagnosis AND lists the remaining Includes an inaccurate diagnosis as the principal addressed at the visit but does not list the Information is completely missing diagnoses addressed at the visit (in diagnosis diagnoses in descending order of priority descending priority) 5 Points Differential Diagnosis 3 Points 2 Points 0 Points Includes at least 3 differential diagnoses for Includes 2 differential diagnoses for the principal Includes 1 differential diagnosis for the principal Information is completely missing the principal diagnosis diagnosis diagnosis 5 Points 3 Points Plan 2 Points 0 Points Pharmacologic treatment plan Diagnostic/Lab Testing Education Anticipatory Guidance Follow up plan Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the 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. Includes a detailed pharmacologic treatment plan Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under for each of the diagnoses listed under “assessment”. The plan includes less than 4 of “assessment”. The plan includes 4 of the the following: the drug name, dose, route, following 7: the drug name, dose, route, frequency, duration and cost as well as education frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis related to pharmacologic agent. If the diagnosis is is a chronic problem, student includes a chronic problem, student includes instructions instructions on currently prescribed medications on currently prescribed medications as above. as above. Information is completely missing 5 Points Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time” 5 Points 3 Points 2 Points 0 Points Includes appropriate diagnostic/lab testing 50% of the time OR acknowledges Discussion: Patient’s Chief Complaint (CC).

“no diagnostic testing clinically required at this time” Includes appropriate diagnostic testing less than 50% of the time. Information is completely missing 3 Points 2 Points 0 Points 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. 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. 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 healthy behaviors into their lives. Information is completely missing 5 Points 3 Points 2 Points 0 Points 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)) Includes at least 2 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)) 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)) Information is completely missing 4 Points Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months) 4 Points 2 Points Includes recommendation for follow up, but does not include time frame (i.e. x # of days/weeks/months) 2 Points 1 Points 0 Points Does not include follow up plan 0 Points 0 Points Moderate level of APA precision Incorrect APA style Information is completely missing 3 Points 2 Points 1 Points 0 Points Free of grammar and spelling errors Writing mechanics need more precision and attention to detail Writing mechanics need serious attention 3 Points 2 Points 0 Points Writing References Grammar High level of APA precision 0 Points SOAP Note Template Encounter date: ________________________ Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____ Reason for Seeking Health Care: ______________________________________________ HPI:_________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________ Current perception of Health: Excellent Good Fair Poor Past Medical History • Major/Chronic Illnesses____________________________________________________ • Trauma/Injury ___________________________________________________________ • Hospitalizations __________________________________________________________ Past Surgical History___________________________________________________________ Medications: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Family History: ____________________________________________________________ Copyright © MVJ 2018 Social history: Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________ Employment Status: ______ Current/Previous occupation type: _________________ Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________ Sexual orientation: _______ Sexual Activity: ____ Contraception Use: ____________ Family Composition: Family/Mother/Father/Alone: _____________________________ Health Maintenance Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____ Exposures: Immunization HX: Review of Systems: General: HEENT: Neck: Lungs: Cardiovascular: Breast: GI: Male/female genital: Copyright © MVJ 2018 GU: Neuro: Musculoskeletal: Activity & Exercise: Psychosocial: Derm: Nutrition: Sleep/Rest: LMP: STI Hx: Physical Exam BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____ General: HEENT: Neck: Pulmonary: Cardiovascular: Breast: Copyright © MVJ 2018 GI: Male/female genital: GU: Neuro: Musculoskeletal: Derm: Psychosocial: Misc. Significant Data/Contributing Dx/Labs/Misc. Plan: Differential Diagnoses 1. 2. 3. Principal Diagnoses 1. Copyright © MVJ 2018 2. Plan Diagnosis Diagnostic Testing: Pharmacological Treatment: Education: Referrals: Follow-up: Anticipatory Guidance: Diagnosis Diagnostic Testing: Pharmacological Treatment: Education: Referrals: Follow-up: Anticipatory Guidance: Copyright © MVJ 2018 Signature (with appropriate credentials): __________________________________________ Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________ DEA#: 101010101 STU Clinic LIC# 10000000 Tel: (000) 555-1234 FAX: (000) 555-12222 Patient Name: (Initials)______________________________ Age ___________ Date: _______________ RX ______________________________________ SIG: Dispense: ___________ Refill: _________________ No Substitution Signature: ____________________________________________________________ Copyright © MVJ 2018 Copyright © MVJ 2018 SOAP Note Template Encounter date: August 5, 2020 Patient Initials: AT Gender: M/F/Transgender: Discussion: Patient’s Chief Complaint (CC).

Female Age: 31-years-old Race: White Ethnicity: Hispanic Reason for Seeking Health Care: Patient states “I have vaginal discharge that sometimes smells like fish or seafood.” Patient is also at office for follow-up post-partum check for episiotomy following vaginal delivery. HPI: 31-year- old female. Past medical history includes subclinical hypothyroidism. Followed by endocrinology for 2 years with stable thyroid function level. Not currently on any medications. Patient presents to office today with a chief complaint of “fishy odor in vagina and vaginal discharge.” Patient gave birth to first baby boy 12 weeks ago via natural birth. Patient does not have other living children and denies miscarriages or abortions. (G1 T1 P0 A0 L1) Patient reports subclinical hypothyroidism was found on incidence and she has never displayed symptoms. Patient states she is otherwise healthy and does not suffer from any other illnesses or conditions. Patient reports receiving wellness checks on a year to year basis and never having an abnormal papsmear or a sexually transmitted disease. Patient is in a monogamous relationship with her husband of three years and she currently uses condoms but would like an IUD placed in the near future and will come back to office when ready. Patient reportedly had IUD removed before getting pregnant and had no complications. Patient is not currently on birth control. Patient denies hormonal imbalances. First menstrual period occurred when she was 11-years-old and her cycle typically occurs every 28-29 days. Patient has not had her first period since giving birth and is breastfeeding infant. Patient noted increase in vaginal discharge and odor one week ago. Denies hematuria, problems urinating, fever, vomiting or any associating symptoms. Patient reports no pain at this time. Copyright © MVJ 2018 Allergies(Drug/Food/Latex/Environmental/Herbal): No Known Allergies to drugs, food, latex, environmental or herbal per mother. Current perception of Health: Excellent Good Fair Poor Past Medical History • Major/Chronic Illnesses: Patient denies any major/ chronic illness. Patient reports subclinical hypothyroidism (not currently on treatment) • Trauma/Injury: Patient denies any injury or trauma. • Hospitalizations: Patient was admitted for two days when she gave birth 12 weeks ago. Patient went home with baby, no complications. Past Surgical History: No surgeries in the past. Medications: Patient currently does not take any medications. Family History: Patient denies any pertinent family medical history. Both parents are alive and healthy per patient. Patient denies knowledge of family history of breast cancer or ovarian cancer. Social history: Lives: Single family House/Condo/ with stairs: Patient lives in a single-family home. Patient reports to live with husband of three years and infant son. Per patient parents moved in earlier in the year to help with baby. Marital Status: married. Employment Status: Employed Current/Previous occupation type: Nurse Copyright © MVJ 2018 Exposure to: Smoke: Denies ETOH: Denies Recreational Drug Use: Patient denies recreational drug use. Sexual orientation: Heterosexual Sexual Activity: Active Contraception Use: Does not currently use any contraceptive methods. Family Composition: Family/Mother/Father/Alone: Patient has both living parents. Patient is married and has one son. Health Maintenance Screening Tests and Assessment tools: Papsmear done at office December 2019 Sexually transmitted Disease exam: August 2020 Pelvic Exam: August 2020 Breast Exam: August 2020 Cervical cancer screening: August 2020 PHQ-9 for depression Exposures: Patient denies exposure to asbestoses and smoke inhalants. Patient denies firearms in the home. Patient states home is equipped with functioning smoke detectors and in-home theft protection alarm. Patient states she wears seatbelt all the time and wears sunscreen. Patient annually gets a checkup and follows recommendations. Immunization HX: HPV: 2008. Hep B: 2000 Flu: 2019 Varicella: titers drawn and immune. Pneumovacc: never received, patient denies. MMR: 1992; titers drawn and patient is immune. Copyright © MVJ 2018 Review of Systems: General: Patient currently denies fatigue, headaches, and malaise. Patient states she has been feeling well and does not have any other complaints at this time. Patient discloses has been eating well but has not started to workout following the birth of her baby. HEENT: Patient denies any changes in vision; no blurriness, double vision or discoloration or discharge. Patient denies any loss of hearing, ear pain or discharge. Denies congestion, runny nose, epistaxis. Denies sore throat, neck swelling and pain. Denies dry mouth or dentition problems. Neck: Patient denies neck discomfort. No enlarged nodes or thyroid. Patient denies neck p …