NURS 6512 Shadow Health Comprehensive SOAP Note Template Worksheet

Assignment 1: You are going to write a SOAP note. Us the template given to you in the Resources section. The skin graphics are also in the Resource section. Choose one graphic to write up for a SOAP note. This is to be written as a SOAP note (NO NARRATIVES). As you write the SOAP note, you must address all sections. If you are not given the information, you will need to make it up.

Make sure that you use medical terminology to describe the image. Include 5 differentials and identify which is the most likely diagnosis. I recommend that you use the SOAP exemplar as a guide for this assignment. NURS 6512 Shadow Health Comprehensive SOAP Note Template Worksheet

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY

Document: Shadow Health Support and Orientation Resources (PDF)

Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us

Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)

Document: Shadow Health Nursing Documentation Tutorial (Word document)

Document: Student Acknowledgement Form (Word document)

Note: You will sign and date this form each time you complete your DCE Assignment in Shadow Health to acknowledge your commitment to Walden University’s Code of Conduct.

Week 9 Case Studies

Shadow Health Comprehensive SOAP Note Template

Patient Initials: _______ Age: _______ Gender: _______

SUBJECTIVE DATA:

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Health Maintenance:

Immunization History:

Significant Family History:

Review of Systems:

General:

HEENT:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Neurological:

Psychiatric:

Skin/hair/nails:

OBJECTIVE DATA:

Physical Exam:

Vital signs:

General:

HEENT:

Neck:

Chest/Lungs:.

Heart/Peripheral Vascular:

Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

Diagnostic results:

ASSESSMENT:

PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses. NURS 6512 Shadow Health Comprehensive SOAP Note Template Worksheet

NURS 6512 Shadow Health Comprehensive SOAP Note Template Worksheet RUBRIC

	Excellent	Good	Fair	Poor
Student DCE score (DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.) Note: DCE Score – Do not round up on the DCE score.	56 (56%) – 60 (60%)DCE score>93	51 (51%) – 55 (55%)DCE Score 86-92	46 (46%) – 50 (50%)DCE Score 80-85	0 (0%) – 45 (45%)DCE Score <79 No DCE completed. NURS 6512 Shadow Health Comprehensive SOAP Note Template Worksheet
Documentation in Provider Notes Area Subjective documentation of the comprehensive exam in Provider Notes is detailed, organized, and includes documentation of identifying data, general survey, reason for visit/chief complaint, history of present illness, medications, allergies, medical history, health maintenance, family history, social history, mental health history, and review of systems. The review of systems is clearly defined by each body system (skin, eyes, cardiac, etc.) and all conditions or illnesses asked of the patient are documented along with the patient response.	16 (16%) – 20 (20%)Documentation is detailed and organized with all pertinent information noted in professional language. NURS 6512 Shadow Health Comprehensive SOAP Note Template Worksheet Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).	11 (11%) – 15 (15%)Documentation with sufficient details, some organization and some pertinent information noted in professional language. Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).	6 (6%) – 10 (10%)Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language. Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).	0 (0%) – 5 (5%)Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language. No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). or No documentation provided. NURS 6512 Shadow Health Comprehensive SOAP Note Template Worksheet
Objective Documentation in Provider Notes – this is to be completed in Shadow Health Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”. Diagnostic result- Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).	16 (16%) – 20 (20%)Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language. Each system assessed is clearly documented with measurable details of the exam. NURS 6512 Shadow Health Comprehensive SOAP Note Template Worksheet	11 (11%) – 15 (15%)Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language. Each system assessed is somewhat clearly documented with measurable details of the exam. NURS 6512 Shadow Health Comprehensive SOAP Note Template Worksheet	6 (6%) – 10 (10%)Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language. Each system assessed is minimally or is not clearly documented with measurable details of the exam.	0 (0%) – 5 (5%)Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language. None of the systems are assessed, no documentation of details of the exam. or No documentation provided.

Excellent

Good

Fair

Poor

Student DCE score

(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.)

Note: DCE Score – Do not round up on the DCE score.

56 (56%) – 60 (60%)DCE score>93

51 (51%) – 55 (55%)DCE Score 86-92

46 (46%) – 50 (50%)DCE Score 80-85

0 (0%) – 45 (45%)DCE Score <79

No DCE completed. NURS 6512 Shadow Health Comprehensive SOAP Note Template Worksheet

Documentation in Provider Notes Area

Subjective documentation of the comprehensive exam in Provider Notes is detailed, organized, and includes documentation of identifying data, general survey, reason for visit/chief complaint, history of present illness, medications, allergies, medical history, health maintenance, family history, social history, mental health history, and review of systems.

The review of systems is clearly defined by each body system (skin, eyes, cardiac, etc.) and all conditions or illnesses asked of the patient are documented along with the patient response.

16 (16%) – 20 (20%)Documentation is detailed and organized with all pertinent information noted in professional language. NURS 6512 Shadow Health Comprehensive SOAP Note Template Worksheet

Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

11 (11%) – 15 (15%)Documentation with sufficient details, some organization and some pertinent information noted in professional language.

Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

6 (6%) – 10 (10%)Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language.

Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

0 (0%) – 5 (5%)Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language.

No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

No documentation provided. NURS 6512 Shadow Health Comprehensive SOAP Note Template Worksheet

Objective Documentation in Provider Notes – this is to be completed in Shadow Health

Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”.

Diagnostic result- Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned

Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).

16 (16%) – 20 (20%)Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language.

Each system assessed is clearly documented with measurable details of the exam. NURS 6512 Shadow Health Comprehensive SOAP Note Template Worksheet

11 (11%) – 15 (15%)Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language.

Each system assessed is somewhat clearly documented with measurable details of the exam. NURS 6512 Shadow Health Comprehensive SOAP Note Template Worksheet

6 (6%) – 10 (10%)Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language.

Each system assessed is minimally or is not clearly documented with measurable details of the exam.

0 (0%) – 5 (5%)Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language.

None of the systems are assessed, no documentation of details of the exam.

No documentation provided.

Total Points: 100

NURS 6512 Shadow Health Comprehensive SOAP Note Template Worksheet