MN552 SOAP Note with Genogram

SOAP Note

Instructions: Enter total points possible in cell C16, under the rubric. Next enter scores (between 0 and 4) into yellow cells only in column F.
Unit 2 – SOAP Note Section 1 Grading Rubric
Unacceptable	Below Average	Average	Above Average	Score	Weight	Final Score	Comments
0	2	3	4
Date and Source of History, Biographical Data	No data addressed.	Data poorly addressed.	Data addressed but more detail is needed or content inconclusive.	Data specific, clear and thoroughly addressed.	0	20%	0.00
Chief Complaint and History of Present Illness	No chief complaint or history of present illness.	Chief complaint and history of present illness poorly addressed.	Chief complaint and history of present illness addressed but more detail is needed or content inconclusive.	Chief complaint and history of present illness specific, clear and thoroughly addressed.	0	20%	0.00
Past Medical and Family History	No past medical or family history.	Past medical and family history poorly addressed.	Past medical and family history addressed but more detail is needed or content inconclusive.	Past medical and family history specific, clear and thoroughly addressed.	0	20%	0.00
Genogram	No genogram.	Genogram poorly addressed.	Genogram depicted but more detail is needed or genogram inconclusive.	Genogram specific, clear and thoroughly addressed.	0	20%	0.00
Organized and well written	No paper submitted.	Paper was unorganized and poorly written.	Paper was somewhat organized and overall writing left room for improvement.	Paper was thoroughly organized and well written.	0	5%	0.00
Ideas stated clearly and logically	No paper submitted.	Ideas were not stated clearly or logically.	Some ideas were stated clearly and logically.	All ideas were stated clearly and logically.	0	5%	0.00
Relevance of Content	No paper submitted.	Paper was off topic and not relevant.	Some portions of paper were on topic and relevant.	Paper was thoroughly on topic and relevant.	0	5%	0.00
Spelling and grammatical errors	No paper submitted.	No formatting guidelines	Less than 6 spelling or grammatical errors.	All formatting guidelines were followed; No spelling or grammatical errors.	5%	0.00
100%	0.00
Final Score	0
Percentage	0.00%
Total available points =	20	4
Rubric Score	Grade points	Percentage
Low	High	Low	High	Low	High
3.5	4.0	18	20	90%	100%
2.5	3.49	16	18	80%	89.99%
1.7	2.49	14	16	70%	79.99%
1.0	1.69	12	14	60%	69.99%
0.0	1.00	0	12	0	59.99%

MN552 Advanced Health Assessment

Unit 2 SOAP Note Section I Written Guide

 

History, Interview, and Genogram Guide

Please select a volunteer friend or family member to interview and gather data to complete this Assignment. The following guide will assist you in gathering subjective data in an organized, systematic manner to prevent omission of important components of the health history. Please remember to attach a Genogram with this Assignment as one document, if possible. You may search the web to locate a suitable Genogram diagram to input data. Only include 3 generations in the genogram depiction. MN552 SOAP Note with Genogram

 

Date of History/Interview:

Source of history and Reliability: (client, family member, chart/record, etc.-sample on page 50 of Jarvis textbook)

1. Biographical Data

a. Name (use initials only)

b. Address

c. Phone number

d. Primary language

e. Authorized representative

f. Age and Date of Birth

g. Place of Birth

h. Gender

i. Race

j. Marital Status

k. Ethnic/Cultural Origin

l. Education ( highest level completed)

m. Occupation/Professional

n. Health insurance

 

2. Chief Complaint (reason for seeking health care):

a. Brief spontaneous statement in client’s own words

b. Includes when the problem started ( “chest pain for 2 hours”)

3. History of Present Illness: A well organized, chronological record of client’s reason for seeking care, from time of onset to present. Please include the 8 critical characteristics using the PQRSTU pneumonic.

P – Provocative or palliative (What brings it on? What makes it better or worse?)

Q – Quality or quantity (Describe the character and location of the symptoms; How does it look, feel, sound?)

R – Region or radiation (Where is it? Does the symptom radiate to other areas of the body?).

S – Severity (Ask the patient to quantify the symptom(s) on a scale of 0-10).

T – Timing (Inquire about time of onset, duration, frequency, etc.)

U – Understand Patient’s Perception of the problem (What do you think it means?)

 

4. Past Medical History

a. Medical Hx: major illnesses during life span, injuries, hospitalizations, transfusions, and disabilities

b. Childhood Illnesses: Measles, mumps, rubella, chickenpox, pertussis, strep throat

c. Surgical Hx; procedures, dates, inpatient or outpatient

d. Obstetric HX: Number of pregnancies, term deliveries, preterm births, abortions

(spontaneous or induced), number of children living

e. Immunizations

f. Psychiatric Hx: childhood and adult (treated or hx of)

g. Allergies: Medications, food, inhalants or other (what occurs with reaction)

h. Current Medications: Include all prescription, herbal/supplements and OTC, dosage, frequency

i. Last Examination Date: Physical, eye exam, foot exam, dental exam, hearing screen, EKG, chest X-Ray, Pap test, mammogram, serum cholesterol, stool occult blood, prostate, PSA, UA, TB skin test; other health maintenance tests for infants/children may include sickle-cell, PKU, lead level, and hematocrit

 

5. Family History (list FHx and design a genogram (computer)-include a key with the genogram). The Genogram must include 3 generations.

a. Include parents, grandparents, spouse, and children.

b. Health conditions, familial and communicable diseases/illnesses

c. Note whether family member deceased or living