23 Feb In patients own words. States the reason for the patient visit in patients own words. For a WELL visit, the chief complaint will be annual exam, check-up, etc. Pediatrics: Child well visit,
health & medical report and need a reference to help me learn.
ACON SOAP Note Template
Note: This template serves as a SOAP note guideline for the Adult and Pediatric patient population in the clinical setting. The SOAP
note should be written in a S-O-A-P format. Information should NOT be placed in the template to stand alone as the SOAP note.
Students Name: Date of Patient Encounter:
Patient initials: Age:
Gender: Male Female Other Ethnicity/Race:
Pediatrics: Child Accompanied by:
SUBJECTIVE DATA
Chief Complaint (CC)
In patients own words. States the reason for the patient visit in patients own words. For a WELL
visit, the chief complaint will be annual exam, check-up, etc.
Pediatrics: Child well visit, sick visit, etc.
History of Present
Illness (HPI)
Must include onset, location, duration/radiation, characteristics, aggravating factors, relieving factors,
timing, and severity (OLDCARTS).
Past Medical History
(PMH)
Current/past medical problems with date of onset.
List all medical problems.
Past Surgical History
(PSH)
Surgeries and procedures with date performed and outcome.
List all surgical procedures.
OB/GYN history
(If applicable)
Gravida/Para. LMP. Last PAP/WWE with results. Last Mammogram with results. History of STI.
DEXA Scan.
2
3.20.19; Revised 7.9.21; 9.7.21
Pediatrics: Pre-Natal History, Newborn Comprehensive History
Immunization Status Age specific immunizations. Covid Vaccine Status.
List and describe any history of reactions.
Medications Current medications: List medication name, dose, route, frequency, duration, and reason for taking
Allergies List medications, foods, environmental, latex as well as how allergy manifested.
List Adverse Drug Reactions (ADRs). Distinguish Side Effect from ADRs.
Family History
(FH)
2nd degree blood relatives (grandparents, parents, siblings, children):
Age, living/deceased, medical problem.
Psychosocial or Social
History (SH)
Patient profile (sexual orientation, marital status, children), lifestyle risk factors (illicit drug use,
alcohol use, smoking/pack year, exercise), employment history, education, religion, cultural history,
support system, living arrangement, stressors, driving.
Military service/deployment. History firearm
Pediatrics:
Developmental
Milestones
0-21 years of age
Nutritional Screening if
applicable
Report findings from a nutritional screening tool used to interview patient
Living Will/Advance
Directives/Advance
Care Planning if
applicable
Report patient wishes and name/relationship of DPOAHC (Health Care Proxy)
Advance Care Planning
Pediatrics: Special Needs
Review of Systems
(ROS)
Subjective information only what the patient reports (example denies, or patient reports) Must
document pertinent patient positive and negative findings.
General
Skin
Head/Neck/Thyroid
EENT
3
3.20.19; Revised 7.9.21; 9.7.21
Cardiovascular
Peripheral Vascular
Respiratory
Gastrointestinal
Reproductive /
Genitalia /
Genitourinary
Musculoskeletal
Neurological
Psychiatric
Endocrine
Hematologic
/Lymphatic
Immune Function /
Dysfunction
4
OBJECTIVE DATA
Physical Exam
General/
Constitutional
General description of patient including age, gender, nutritional status, habitus, attention to grooming,
state of cooperativeness/demeanor, overall picture of wellness/distress
Vital Signs Temperature, Pulses, Respirations, BP (Postural PRN), Height, Weight, BMI, O2 sat (if applicable)
Pediatrics: Vital Signs Head Circumference
BP start at 3 years of age
Growth Chart Percentages (until age 21)
Pediatrics: Vital Signs
Skin
Head/Neck
EENT
Respiratory
Cardiovascular
Peripheral Vascular
Abdomen
Breast
Female Genitourinary/
GYN
(If applicable)
Male Genitourinary/
Prostate
(If applicable)
Musculoskeletal
5
(Including frailty
evaluation if applicable)
Neurological Mental status, cranial nerves, motor, cerebellum, motor, cerebellum, sensory, reflexes
Psychiatric Including
Mental Health/
Substance Use Screening
Tools and Interpretation
of Results
Document findings from depression screen, Mini-Mental Status Exam, CAGE, GAD, PHQ2/9 etc.
Pediatrics: Screen for Autism (MCHAT)
Lymphatic
Diagnostic
Information
Results of diagnostic testing conducted at the time of the visit OR previously done and being used to
support the diagnosis and management plan for the current visit
PRIMARY DIAGNOSIS FOR THIS VISIT
ICD-10 Code Primary Diagnosis(es)
1.
2.
3.
DIFFERENTIAL DIAGNOSE/CHRONC CONDITIONS AND SUPPORTING DATA
ICD-10 Code
1.
2.
3.
4.
6
TREATMENT PLAN
(For graded SOAP note submissions, include rationale for all components of treatment plan)
Additional Diagnostic Tests
Needed
Treatments: Pharmacological
Treatments:
Non-Pharmacological
Patient Education
Pediatrics: Anticipatory
Guidance
Consultations/Referrals
Recommended With
Rationale
Disposition Next office visit scheduled, identify the plan for follow-up, note expectations for further treatment.
Two Current Evidence-Based Guidelines and/or Peer-Reviewed Scholarly Journals to Support Patient Education and
Treatment Plan
7
CPT Billing Codes Reflected in the Treatment Plan
CPT Code Corresponding Diagnosis
1. Office visit E/M code
2.
3.
4.
5. Point of care testing (urine dipstick, wet
mount, x rays, etc.) and resulted IN
OFFICE, and any procedures done in
office
ONE EPISODIC SOAP NOTE, ONE FOCUS SOAP NOTE.
Use the ACON SOAP Note template as a guide
Identify and collect relevant subjective and objective data
Use proper medical terminology and documentation
Use proper ICD-10 coding and Current Procedural Terminology (CPT) E/M coding
Identify any cultural/religious/racial/gender influences on care
Assignment Criteria:
Students will complete a Soap note and include the following:
Subjective findings
Chief complaint (CC)
History of present illness (HPI)
Use mnemonic: onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, and severity (OLDCARTS)
Past medical/surgical/social/family history
Medications
Allergies, prescription/over the counter (OTC)/herbal medications
Comprehensive review of systems (ROS)
Objective findings
Appropriate physical examination based on subjective findings
Relevant positive and negative diagnostic testing including previous pertinent diagnostic tests related to visit
Screening tools and positive and negative results
Assessment
Correct primary diagnosis
Correct differential diagnoses
Correct ICD-10/Current Procedural Terminology (CPT) codes
Plan
Identify and orders correct diagnostics, prescriptions, referrals, and follow-up plan
Patient education relative to treatment plan.
Correctly written out a prescription for one medication prescribed for the patient.
If a medication not prescribed, write out a prescription for a medication that might be prescribed for a similar patient
Include two current evidence-based guidelines and/or peer-reviewed scholarly journals to support patient education and treatment plan. The student can pick one evidence-based guideline and one scholarly article. References should be from scholarly peer-reviewed journals (check Ulrich’s Periodical Directory) and be less than five (5) years old.
APA format required (attention to spelling/grammar, a title page, a reference page, and in-text citations).
Submit by the posted due date.
View Rubric
ACON SOAP Note Grading Tool-5 points
ACON SOAP Note Grading Tool-5 points
Criteria Ratings Pts
Subjective Findings
view longer description
1.5 pts
Proficient
Documents all relevant subjective information.
1 pts
Competent
Partially documents relevant subjective information.
0.25 pts
Novice
Incomplete documentation of relevant subjective information.
/ 1.5 pts
Objective Findings
view longer description
1 pts
Proficient
Documents all relevant objective information including positive and negative findings.
0.5 pts
Competent
Partially documents relevant objective information including positive and negative findings.
0 pts
Novice
Incomplete documentation of relevant objective information and omits large amounts of positive and negative findings.
/ 1 pts
Assessment
view longer description
1 pts
Proficient
Documents correct primary diagnosis and two differential diagnoses with ICD-10/ CPT codes.
0.5 pts
Competent
Documents correct primary diagnosis and one differential diagnosis with ICD-10/ CPT codes.
0 pts
Novice
No primary diagnosis and/or differential diagnoses with ICD-10/ CPT codes.
/ 1 pts
Plan
view longer description
1 pts
Proficient
Plan includes diagnostics, prescription, referrals, patient education, and recommended follow-up. One prescription included.
0.5 pts
Competent
Plan partially complete and/or partially diagnosis centered and/or addresses partial components of prescriptions, referrals, patient education, and recommended follow-up and/or no prescription included.
0.25 pts
Novice
Plan documents limited or inappropriate plan of care and/or missing prescription included.
/ 1 pts
Source
view longer description
0.5 pts
Proficient
Two current evidence-based guidelines and/or peer-reviewed scholarly journals to included supporting patient education and treatment plan. All references are from a relevant professional peer-reviewed scholarly source, and within a 5-year timeframe.
0.25 pts
Competent
One current evidence-based guidelines and/or peer-reviewed scholarly journals to included supporting patient education and treatment plan. All references are from a relevant professional peer-reviewed scholarly source, and within a 5-year timeframe.
0 pts
Novice
No evidenced-based guideline used.
/ 0.5 pts
APA
view longer description
0 pts
Competent
Up to 10% of the assigned points (total points of assignment) can be deducted from the earned points for errors in APA style [title page, citations, reference, and format], spelling, and/or grammar.
0 pts
Novice
Up to 10% of the assigned points (total points of assignment) can be deducted from the earned points for errors in APA style [title page, citations, reference, and format], spelling, and/or grammar.
0 pts
Proficient
Up to 10% of the assigned points (total points of assignment) can be deducted from the earned points for errors in APA style [title page, citations, reference, and format], spelling, and/or grammar.
/ 0 pts
Requirements: VARIES
