Graded SOAP Notes
Criteria/Rubric
Comprehensive Care Format
Annual Health Maintenance /New Patient to Establish Care
S: SUBJECTIVE Information - Health History ( /30 Points)
1 point Biographical Information
Date of visit, practice setting, and general demographic /biographical information about
patient; including age, gender, ethnicity, marital status, occupation, living situation,
source of history, referral source, reliability of informant, insurance type.
2 points Reason for Visit (1) and Chief Complaint (1)
6 points History of Present Illness (Symptom Analysis) or Interval Health (since last visit)
3 points Current Health Status – medications, allergies, etc.
3 points Past Health Status
3 points Family Health Status (use Genogram)
6 points Complete Review of Systems
2 points Psychosocial History
2 points Health Promotion/Maintenance Activities
2 points Environmental Health
O: OBJECTIVE Information - Physical Examination ( /25 Points)
1 points General Survey & Vital Signs
3 points Mental Status Examination and Neurological Assessment
3 points HEENT Assessment
3 points Cardiovascular Assessment
3 points Pulmonary & Thorax Assessment
3 points Abdominal Assessment
, 3 points Genitourinary Assessment
3 points Musculoskeletal Assessment
3 points Integument Assessment
---- Laboratory and/or Diagnostic Test Results (if applicable)
A: ASSESSMENT/ Clinical Impressions ( /15 Points)
3 points Risk Profile
2 points Client Profile
10 points Complete Problem List (including any differential diagnoses, if appropriate).
Include a thorough impression for each problem.
• Specify ICD-10 codes for all diagnoses listed.
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• Indicate status of the problem –acute, chronic, stable, acute-on-chronic, improving,
resolved, etc.
Prognosis:
• Discuss the long-term health implications of people with this/these clinical condition(s)
as a whole (not individual diagnoses), and in terms of your particular patient.
P: PLAN of Care ( /20 points)
Organize the plan to include each component as part of ongoing maintenance/care
(systematically addressing the narrative descriptors that follow):
• Diagnostic Testing (labs, radiography, functional/cognitive tests, etc.);
• Treatments Ordered (medications, therapeutics, referrals to specialists/therapy, etc.);
• Patient/Family Education; (instruction, materials, community resources, etc.)
• Follow up /need to return plan.
Considerations in plan development—discuss:
• What more do I need to know? Any further assessment that must be done to reach or
confirm accurate clinical impression, i.e. diagnostic or laboratory studies.
• What interventions were done or need to be done? Strategies such as medications,
treatments, therapies, and referrals to other health care providers; discuss medications in
terms of indications, actions, pharmacodynamics, possible adverse drug reactions and
Criteria/Rubric
Comprehensive Care Format
Annual Health Maintenance /New Patient to Establish Care
S: SUBJECTIVE Information - Health History ( /30 Points)
1 point Biographical Information
Date of visit, practice setting, and general demographic /biographical information about
patient; including age, gender, ethnicity, marital status, occupation, living situation,
source of history, referral source, reliability of informant, insurance type.
2 points Reason for Visit (1) and Chief Complaint (1)
6 points History of Present Illness (Symptom Analysis) or Interval Health (since last visit)
3 points Current Health Status – medications, allergies, etc.
3 points Past Health Status
3 points Family Health Status (use Genogram)
6 points Complete Review of Systems
2 points Psychosocial History
2 points Health Promotion/Maintenance Activities
2 points Environmental Health
O: OBJECTIVE Information - Physical Examination ( /25 Points)
1 points General Survey & Vital Signs
3 points Mental Status Examination and Neurological Assessment
3 points HEENT Assessment
3 points Cardiovascular Assessment
3 points Pulmonary & Thorax Assessment
3 points Abdominal Assessment
, 3 points Genitourinary Assessment
3 points Musculoskeletal Assessment
3 points Integument Assessment
---- Laboratory and/or Diagnostic Test Results (if applicable)
A: ASSESSMENT/ Clinical Impressions ( /15 Points)
3 points Risk Profile
2 points Client Profile
10 points Complete Problem List (including any differential diagnoses, if appropriate).
Include a thorough impression for each problem.
• Specify ICD-10 codes for all diagnoses listed.
Page 17 of 1
• Indicate status of the problem –acute, chronic, stable, acute-on-chronic, improving,
resolved, etc.
Prognosis:
• Discuss the long-term health implications of people with this/these clinical condition(s)
as a whole (not individual diagnoses), and in terms of your particular patient.
P: PLAN of Care ( /20 points)
Organize the plan to include each component as part of ongoing maintenance/care
(systematically addressing the narrative descriptors that follow):
• Diagnostic Testing (labs, radiography, functional/cognitive tests, etc.);
• Treatments Ordered (medications, therapeutics, referrals to specialists/therapy, etc.);
• Patient/Family Education; (instruction, materials, community resources, etc.)
• Follow up /need to return plan.
Considerations in plan development—discuss:
• What more do I need to know? Any further assessment that must be done to reach or
confirm accurate clinical impression, i.e. diagnostic or laboratory studies.
• What interventions were done or need to be done? Strategies such as medications,
treatments, therapies, and referrals to other health care providers; discuss medications in
terms of indications, actions, pharmacodynamics, possible adverse drug reactions and
