| Criteria | Exceeds Expectations | Meets Expectations | Below Expectations | Far Below Standard |
| Identifying Data | 5 points Correctly lists all components of the Identifying data including initials, age, DOB, gender, race, ethnicity and whether they came to clinic alone or accompanied and if they are a reliable historian. |
4 points Missing one of the elements, or not written in a complete/logical sentence. |
2 points Missing 2 or more items. |
0 points Not included or written in the wrong area (only in HPI instead of separately). |
| Chief Complaint | 5 points Listed the chief complaint in patient’s own words with quotation marks “complaint”. CC is brief and not over a sentence long. |
4 points Missing one element (not in quotations, not in patients own words, etc). |
2 points Incomplete not in the patient’s own words. |
0 points Not Included |
| History of present illness | 15 points HPI written succinctly in paragraph format. If the patient has no complaints (such as a wellness visit), the student summarizes the past health history including mo/year of last physical and any pertinent health maintenance or recent lab work. For problem visits, the HPI narrates a story of the patient’s problem. If there is a complaint, all elements of HPI are addressed (OLDCARTs or OPQRST) as appropriate for complaint. |
13 points Most elements addressed, missing one or two items, but not missing an item that would severely change the treatment of patient. |
10 points For any complaint, missing 3 or more of the 7 HPI elements. Or for an annual exam, missing health maintenance history or summary of patient’s overall health. Missing an item that would alter the treatment. |
7 points <5 variables identified, or not included. May give a zero if not included. Did not provide a synopsis of the patient’s problem or health status. |
| Past Medical History | 15 points All elements of PMH are described, including medical problem list, surgical history with mo./year of procedure or hospitalization, allergies to environment, food, and drugs, list of meds with doses, and any chemical history (alcohol, drugs, tobacco, caffeine), immunization status. LMP must be included for women of child bearing age. For problem visit, the medical history is pertinent to the problem but meets minimum safety requirements, and always included smoking and allergy information. For wellness exam student expands on diet/nutrition history as well as well as immunizations and health maintenance activities (exercise, sleep, stress). |
12 points Mostly complete; missing 1-2 items. May provide too much detail for problem focused visit, or too little detail for wellness exam. |
9 points Incomplete, missing 3-4 items or too little detail. |
7 points Missing more than half the information. May give a zero if not included. |
| Family History and Social History | 10 points For wellness visit, student must include list of relatives including siblings, children, parents, and grandparents and list ages and health problems. For problem visit, provides family history that is pertinent to the problem, such as asking patient about family hx of GI diseases if the pt has a GI compliant. Social history: Student includes occupation, education, housing situation, marital or relationship status, sexual history and practices, spiritual history, and safety practices (guns in home, seat belts, etc., and elaborates even more for children). For problem focused visit, the student includes the social aspects that are pertinent to the problem. |
8 points Mostly complete; missing 1-2 items, or giving far too much detail than would be required for problem focused visit (i.e writing about every sexual partner or onset of menses on a visit for simple earache) or documenting too little information for a wellness exam. |
6 points Incomplete, missing 3 or more items, or far too much documentation than is required. |
4 points Missing more than half the information. May give a zero if not included. |
| Review of Systems | 15 points Student includes a complete ROS for an annual/wellness exam and an expanded or problem pertinent ROS for a problem-focused visit. The student asks several questions in each category that pertains to the visit. For a wellness exam, the student should review all systems. The student uses the official 14 systems as outlined by page 7 of DHHS/CMS. DHHS/CMS official documentation |
12 points Mostly complete; missing 1-2 items. Student may have extra/unnecessary systems for a problem visit or missing 1-2 systems on a wellness exam. |
10 points Not comprehensive or not problem focused. Asked only 1 question from each system, or missing more than 2-3 systems, or, for problem focused, contained many extraneous, unnecessary items. Or used an ROS list that is not official. |
8 points Incomplete or missing pertinent positives, incomplete or missing pertinent negatives, more than half systems missing. May give a zero if ROS not performed. |
| Objective/Physical Exam Write Up | 15 points For all visits, includes vital signs. All peds visits include H/W. For wellness exams and as needed for other visits, includes height/weight/BMI, head circumference (< 2 y.o.). Includes proper documentation of comprehensive physical exam findings with proper medical terminology, as appropriate for the patient’s complaint. A full physical is written up for an annual/wellness exam. Exam is age appropriate (includes tanner stages and primitive reflexes as applies to children and infants) |
12 points May have missed 1-2 aspects of the physical exam write up, or included extra systems that are not necessary for the patient complaint. Some terminology is inappropriate or not professional (i.e. using laymen’s terms or non-medical terms). |
9 points Missed vital signs or several aspects of the physical exam write up. Included items that do not align with the complaint. |
6 points Missing over half of the physical exam. |
| Assessment and Plan | 15 points Student provides a DDX list with at least 3 differentials considered. Student indicates their chosen diagnosis and brief written synopsis of decision making for the diagnosis. Treatment plan includes diagnostic plan, therapeutic plan, patient education (including SEs of meds if ordered) and specific follow up. For well child exams, includes anticipatory guidance/next immunizations. Student specifies labs and radiology and referrals as needed. Student documents any ordered medications as appropriate at provider level; with correct medication form, doses, routes, timing, # ordered, and refills if indicated. |
12 points Assessment and plan is mostly complete, maybe missing one element. Did not include DDx list. Missing a detail of the prescription. Missing details of labs or rads or referrals. |
10 points Student is missing or several elements of plan or did not clearly indicate the diagnosis. Only mentions the prescription name. |
5 points Missing over half the A/P elements, or if not included at all may score the student a zero |
| Format, spelling/grammar, and references | 10 points APA format, spelling, and grammar is appropriate. Sentence fluency is present and content is organized and well-written. SOAP note format is organized and easy to follow with clear headings for ID, CC, HPI, History, ROS, VS/PE, Assessment, and Plan and all subsections. There are at least two in-text citations (with matching references) to support the clinical decision making (i.e. support the DX or the treatment plan chosen). Student uses references that are evidence-based, peer-reviewed, and published within the last 5 years and that align with the scope of practice (i.e. provider focused references vs only nursing focused). |
8 points APA format is mostly correct with minimal errors. The format has 1-2 errors but they are minor. The student only uses one reference, or does not cite or write the references appropriately. |
6 points Several formatting or APA issues. Student does not use citations or references, or they chose references that are inappropriate. |
4 points Very poor or no APA format, poor SOAP format, or missing a portion of the SOAP note, or does not use any references. |
Wellchild Soap Note