39222SKIN! SKIN! SKIN!!!!!
Dermatologic SOAP Note
Review the Focused Note Checklist provided in this week’s Learning Resources and consider how you will develop your Focused Note for this week’s Assignment.Use the Focused SOAP Note Template and the example found in the Learning Resources for this week to complete this Assignment.Select an adolescent patient that you examined during the last 3 weeks. With this patient in mind, address the following in a Focused Note. Assignment
Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
RUBRIC:PRAC_6541_Week6_Assignment2_RubricPRAC_6541_Week6_Assignment2_RubricCriteria Ratings PtsThis criterion is linked to a Learning OutcomeOrganization of Write-up30 to >26.0 ptsExcellentAll information organized in logical sequence; follows acceptable format26 to >23.0 ptsGoodInformation generally organized in logical sequence; follows acceptable format23 to >20.0 ptsFairErrors in format; information intermittently organized20 to >0 ptsPoorErrors in format; information disorganized30 ptsThis criterion is linked to a Learning OutcomeThoroughness of History20 to >17.0 ptsExcellentThoroughly documents all pertinent history components for type of note; includes critical as well as supportive information17 to >15.0 ptsGoodDocuments most pertinent history components; includes critical information15 to >13.0 ptsFairFails to document most pertinent history components; Lacks some critical information or rambling in history13 to >0 ptsPoorMinimal history; critical information missing20 ptsThis criterion is linked to a Learning OutcomeThoroughness of Physical Exam10 to >8.0 ptsExcellentThoroughly documents all pertinent examination components for type of note8 to >7.0 ptsGoodDocuments most pertinent examination components7 to >6.0 ptsFairDocuments some pertinent examination components6 to >0 ptsPoorPhysical examination cursory; misses several pertinent components10 ptsThis criterion is linked to a Learning OutcomeDiagnostic Reasoning10 to >8.0 ptsExcellentAssessment consistent with prior documentation. Clear justification for diagnosis. Notes all secondary problems. Cost effective when ordering diagnostic tests8 to >7.0 ptsGoodAssessment consistent with prior documentation. Clear justification for diagnosis. Notes most secondary problems.7 to >6.0 ptsFairAssessment mostly consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests6 to >0 ptsPoorAssessment not consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests10 ptsThis criterion is linked to a Learning OutcomeTreatment Plan/Patient Education10 to >8.0 ptsExcellentTreatment plan and patient education addresses all issues raised by diagnoses, excellent insight into patient’s needs. Evidence based decisions. Cost effective treatment. Reflection is thoughtful and in depth.8 to >7.0 ptsGoodTreatment plan and patient education addresses most issues raised by diagnoses. Reflection is thoughtful and in depth.7 to >6.0 ptsFairTreatment plan and patient education fail to address most issues raised by diagnoses. … Reflection is brief, vague. and does not discuss anything that would have been done in addition to or differently.6 to >0 ptsPoorMinimal treatment plan and/or patient education addressed … Reflection is absent.10 ptsThis criterion is linked to a Learning OutcomeWritten Expression and FormattingEnglish writing standards: Correct grammar, mechanics, and proper punctuation.10 to >8.0 ptsExcellentUses correct grammar, spelling, and punctuation with no errors.8 to >7.0 ptsGoodContains a few (1-2) grammar, spelling, and punctuation errors.7 to >6.0 ptsFairContains several (3-4) grammar, spelling, and punctuation errors.6 to >0 ptsPoorContains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.10 ptsThis criterion is linked to a Learning OutcomeWritten Expression and FormattingThe assignment follows parenthetical/in-text citations, and at least 3 evidenced based references are listed.10 to >8.0 ptsExcellentContains parenthetical/in-text citations and at least 3 evidenced based references are listed.8 to >7.0 ptsGoodContains parenthetical/in-text citations and at least 2 evidenced based references are listed7 to >6.0 ptsFairContains parenthetical/in-text citations and at least 1 evidenced based reference is listed6 to >0 ptsPoorContains no parenthetical/in-text citations and 0 evidenced based references listed.10 ptsTotal Points: 100
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39222SKIN! SKIN! SKIN!!!!!