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Assignment Prompt & Instructions

References and please verify with Rubric

– 2 years ago

**files (2)**

– ## MSNSoapNoteRubricElsaPreceptor.pdf

– ## SoapNoteConstipatiion..docx

**## MSNSoapNoteRubricElsaPreceptor.pdf**

SOAP NOTE RUBRIC

Criteria Points Competent Need Improvement Not Acceptable

Score

Subjective (35 points) Provides
complete, concise,
and accurate
information,
which is well
organized and
easy to
understand.

Provides most of the
pertinent
information, but is
not well organized
and/or is slightly
challenging to
understand. May be
missing pertinent
negative information
(e.g., patient
denies…).

Limited or no
summary of
pertinent
information, is
organized
poorly, contains
inaccurate
information,
and/or is
difficult to
understand.

Chief complaint 5 5 3 1
HPI 10 10 8 6
Relevant PMH & FH 5 5 3 1
ROS 10 10 8 6
Currents: Allergies,
Meds/OTCs, Tobacco,
Immunizations, Diet, Exercise,
Sleep

5 5 3 1

Objective (40 points) Provides
complete, concise,
and accurate
information,
which is well
organized and
easy to
understand.

Provides most of the
pertinent
information, but is
not well organized
and/or is slightly
challenging to
understand. May be
missing pertinent
negative information
(e.g., patient denies)

Limited or no
summary of
pertinent
information, is
organized
poorly, contains
inaccurate
information,
and/or is
difficult to
understand.

General survey (Describe the
state of the patient at the time
of the examination)

10 10 8 6

Vital signs
Height, Weight, BMI

10 10 8 6

Physical exam-systematic,
organized and thorough and
related to the reason of the visit

20 20 18 16

Diagnosis/ Differentials
Diagnosis (10 points)

Main diagnosis/
Differentials
Diagnosis is
supported by the
objective and
subjective
assessment and
rationale for
choosing the

Main diagnosis/
Differentials
Diagnosis is
supported by the
objective and
subjective assessment
but the rationale for
choosing the
diagnosis is not

Main diagnosis/
Differentials
Diagnosis is not
supported by
the objective
and subjective
assessment and
the rationale for
choosing the

SOAP NOTE RUBRIC

diagnosis is
supported by the
evidence

supported by the
evidence

diagnosis is not
supported by
the evidence

Diagnosis/(Assessment) 5 5 3 1
List of differentials supported
by S+O findings (5 points)
Must provide 3 differential
diagnoses with one citation
for each diagnosis.

5 5 3 1

Plan of care (10 Points) Complete and
appropriate plan
for the main
problem and
other active
problems.
Includes
pharmacologic
and/or non-
pharmacologic
and/or complete
sig components.

Mostly complete and
appropriate plan for
the main problem
and other active
problems. May be
missing appropriate
non-pharmacologic
treatments and/or sig
components.

Missing or
inappropriate
treatment plan
for the main
problem and
other active
problems.

Diagnostic
tests/therapies/medications

5 5 3 1

Follow-up/Pt. Education and
Health Promotion

5 5 3 1

References (5 Points) Provides a
complete and
appropriate list of
references that
are in APA
format.

References listed are
appropriate (i.e.
guidelines or
primary), but not
complete and some
may be missing. Not
APA formatted.

References
missing or very
limited.
References
listed are
inappropriate
(i.e. tertiary)
and/or not
relevant.

References 5 5 3 1
Total 100

Comment:

**## SoapNoteConstipatiion..docx**

| | | |
| — | — | — |
| **Patient Initials: RH** | **Pt. Encounter Number: 2-5** |
| **Date: 1/15/2025** | **Age: 81 y.o** | **Sex: Male** |
| **Allergies: NKA Advanced Directives: On File** |
| **SUBJECTIVE** |
| **CC:** _“I have abdominal pain and bloating, my abdomen feels tight, and I haven’t had a bowel movements for 7 days. I feels nauseous and I have vomited.”_ |
| **HPI:** 81 y/o Male with Hx of HTN, achalasia, dementia and chronic constipation. Patient presents with constipation with colonic dilation and cecal pneumatosis. Reports bloating and abdominal discomfort. No significant rectal bleeding or weight loss. On 1/14 RRT called due to hypotension and concerns for evolving sepsis. **_Onset:_** 7 days ago **_Location:_** 4 ABD Quadrants **_Duration:_** Continuous **_Characteristics:_** Burning, Sharp Pain **_Aggravating Factors:_** Eating. Laying Flat **_Relieving Factors:_** Eating small, simple seasoning meals. Antacids. **_Treatment:_** CT ABD Scan STAT ordered, Surgical team on board, labs CBC, BMP, Aptt, PT/INR, blood cx. Close monitoring in ICU. |
| **Current Medications:** Insulin, Pulmicort, Donepezil, Memantine, Trazadone, Labetalol, Pantoprazole, TPN, Lipids. |
| **PMH:** HTN, Achalasia Dementia, Chronic- constipation **Medication Intolerances: None** **Chronic Illnesses/Major traumas:** HTN, IDDM, Dementia, Constipation **Screening Hx/Immunizations Hx:** Up to Date, Influenza and Pneumococcal. **Hospitalizations/Surgeries:** 1/9 s/p initial Exploratory Laparotomy, decompression of colon, loop transverse colostomy, and placement of gastrostomy tube. |
| **Family History:** Father-61 years old died from Pneumonia. Mother-76 years old died from Asthma and HTN. |
| **Social History:** _Patient comes from nursing home. Denies Tabacco, alcohol or drug use in the past. Ambulatory assist, requires a walker. Fall precautions in place._ |
| **ROS** |
| **General** AAOx2, appears in discomfort, multimodal pain control due to distention and bloating. | **Cardiovascular** · Hemodynamic monitoring and management. · Titrate pressors to maintain MAP >65. · Levophed at 4 mcg, wean as tolerated. · Will place Arterial Line for invasive BP monitoring. |
| **Skin** Pale, Cold and Dry. | **Respiratory** · Pt continues Ertapenem for resistant Klebsiella PNA in blood · Maintain SpO2 >92 %. · Continue pulmonary toilet · Encourage use of I/S |
| **Eyes** Denies visual loss, blurred vision, or double vision. Denies history of cataracts or glaucoma. Uses glasses. | **Gastrointestinal** · NPO Status · Continue TPN, Lipids · Gi Px: Protonix · Continue ostomy care, monitor output · General Surgery Following. |
| **Ears** History of otitis externa. Denies recent infections, ear pain, or tinnitus. Hard of hearing. | **Genitourinary/Gynecological** No acute issues: Denies urinary urgency, frequency, dysuria, odorous urine, suprapubic pain. · Continue monitoring of renal function, I/O, and electrolytes. Replace PRN. |

| | | |
| — | — | — |
| | |
| **Nose/Mouth/Throat** Denies nasal pain, drainage, congestion, or other sinus issues. Denies throat pain or swelling. | **Musculoskeletal** ROM limited. Denies muscle pain. · PT/OT ordered · OOB to Chair |
| **Breast** Denies discharge, tenderness. No palpable mass during exam. | **Neurological** Awake and Alert. Hx of dementia. Continue Donepezil, Memantine, Trazadone. |
| **Heme/Lymph/Endo** · Insulin sliding Scale- for Blood Glucose <180 · Afebrile, leukocytosis · Pt continues Ertapenem for resistant Klebsiella PNA in blood. · ID Following | **Psychiatric** Calm and cooperative. |
| **OBJECTIVE** |
| **Weight 133 lbs BMI 22.86** | **Temp 96.1** | **BP 108/54** |
| **Height 5’4”** | **Pulse 84** | **Resp 17** |
| **PHYSICAL EXAMINATION** |
| **General Appearance** Patient with normal appearance. Currently sleeping, easy to arouse. Weakness, fatigue, weight loss. No distress noted. Denies pain or discomfort at the moment. |
| **Skin** Skin is intact, warm, dry, and adequate color. Normal skin turgor. Capillary refills < 3 seconds. |
| **HEENT** Head in normocephalic/atraumatic. Visual field full by confrontation. Conjunctiva pink, sclera white. Pupils 3 mm equally, round react to light and accommodation. EOM intact. No nose discharged noted. Fontal sinuses non-tender to palpation. No bleeding gum noted. Buccal mucosa dry, pink, and intact. Uvula midline, no exudate noted. No JVD noted. |
| **Cardiovascular** Currently NSR. No murmurs noted upon auscultation. Denies Chest Pain. |
| **Respiratory** Clear to auscultation bilaterally. Saturation 99-100 % on NC 4 L. |
| **Gastrointestinal** Abdomen hard, rounded, distended, tender to palpation, hypoactive bowel sounds noted. Right abdominal colostomy w/ stool output and pink stoma. PGJ tube in place. Midline incision with staples noted, open to air, no drainage. |
| **Breast** No lumps noted on palpation. Symmetrical. |
| **Genitourinary** No inguinal Hernias or CVA tenderness. Urine clear and yellow. Monitor I/O. |
| **Musculoskeletal** Pain with ambulation. Weaknesses. Limited ROM. No cyanosis or pedal edema. |
| **Neurological** AAOx2, self and place, partially to situation, disoriented to time. Speech clear, forgetful. Following commands. Able to move all extremities equally. Weakness BL upper and Lower extremities. Denies headache or dizziness. |
| **Psychiatric** Patient with noted depression and light anxiety. |
| **Lab Tests:** CBC, BMP, Aptt, PT/INR, blood cx |

| |
| — |
| |
| **Special Tests:** Surgical Consult, CT ABD w/o contrast, Xray-ABD (KUB) |
| **Diagnosis** |
| · Primary Diagnosis-  Constipation, Achalasia. o Differential Diagnoses **:** Colon perforation, Acute colonic Pseudo Obstruction, Ischemic Colitis. Sepsis. o **Plan:**  CT ABD w/o Contrast STAT, Chest Xray, Labs including Blood cultures  Medication: Continue Invanz, Levophed  Education: NPO status, Incentive Spirometer use.  Will place A-Line for invasive BP monitoring, Strict I/O · Referrals: Surgical Consult on board, ID Following. PT/OT  Follow-up for new cultures and CT scan STAT and general surgery recommendations. |
| **References** |

SOAP NOTE

**## SoapNoteConstipatiion..docx**

| | | |
| — | — | — |
| **Patient Initials: RH** | **Pt. Encounter Number: 2-5** |
| **Date: 1/15/2025** | **Age: 81 y.o** | **Sex: Male** |
| **Allergies: NKA Advanced Directives: On File** |
| **SUBJECTIVE** |
| **CC:** _“I have abdominal pain and bloating, my abdomen feels tight, and I haven’t had a bowel movements for 7 days. I feels nauseous and I have vomited.”_ |
| **HPI:** 81 y/o Male with Hx of HTN, achalasia, dementia and chronic constipation. Patient presents with constipation with colonic dilation and cecal pneumatosis. Reports bloating and abdominal discomfort. No significant rectal bleeding or weight loss. On 1/14 RRT called due to hypotension and concerns for evolving sepsis. **_Onset:_** 7 days ago **_Location:_** 4 ABD Quadrants **_Duration:_** Continuous **_Characteristics:_** Burning, Sharp Pain **_Aggravating Factors:_** Eating. Laying Flat **_Relieving Factors:_** Eating small, simple seasoning meals. Antacids. **_Treatment:_** CT ABD Scan STAT ordered, Surgical team on board, labs CBC, BMP, Aptt, PT/INR, blood cx. Close monitoring in ICU. |
| **Current Medications:** Insulin, Pulmicort, Donepezil, Memantine, Trazadone, Labetalol, Pantoprazole, TPN, Lipids. |
| **PMH:** HTN, Achalasia Dementia, Chronic- constipation **Medication Intolerances: None** **Chronic Illnesses/Major traumas:** HTN, IDDM, Dementia, Constipation **Screening Hx/Immunizations Hx:** Up to Date, Influenza and Pneumococcal. **Hospitalizations/Surgeries:** 1/9 s/p initial Exploratory Laparotomy, decompression of colon, loop transverse colostomy, and placement of gastrostomy tube. |
| **Family History:** Father-61 years old died from Pneumonia. Mother-76 years old died from Asthma and HTN. |
| **Social History:** _Patient comes from nursing home. Denies Tabacco, alcohol or drug use in the past. Ambulatory assist, requires a walker. Fall precautions in place._ |
| **ROS** |
| **General** AAOx2, appears in discomfort, multimodal pain control due to distention and bloating. | **Cardiovascular** · Hemodynamic monitoring and management. · Titrate pressors to maintain MAP >65. · Levophed at 4 mcg, wean as tolerated. · Will place Arterial Line for invasive BP monitoring. |
| **Skin** Pale, Cold and Dry. | **Respiratory** · Pt continues Ertapenem for resistant Klebsiella PNA in blood · Maintain SpO2 >92 %. · Continue pulmonary toilet · Encourage use of I/S |
| **Eyes** Denies visual loss, blurred vision, or double vision. Denies history of cataracts or glaucoma. Uses glasses. | **Gastrointestinal** · NPO Status · Continue TPN, Lipids · Gi Px: Protonix · Continue ostomy care, monitor output · General Surgery Following. |
| **Ears** History of otitis externa. Denies recent infections, ear pain, or tinnitus. Hard of hearing. | **Genitourinary/Gynecological** No acute issues: Denies urinary urgency, frequency, dysuria, odorous urine, suprapubic pain. · Continue monitoring of renal function, I/O, and electrolytes. Replace PRN. |

| | | |
| — | — | — |
| | |
| **Nose/Mouth/Throat** Denies nasal pain, drainage, congestion, or other sinus issues. Denies throat pain or swelling. | **Musculoskeletal** ROM limited. Denies muscle pain. · PT/OT ordered · OOB to Chair |
| **Breast** Denies discharge, tenderness. No palpable mass during exam. | **Neurological** Awake and Alert. Hx of dementia. Continue Donepezil, Memantine, Trazadone. |
| **Heme/Lymph/Endo** · Insulin sliding Scale- for Blood Glucose <180 · Afebrile, leukocytosis · Pt continues Ertapenem for resistant Klebsiella PNA in blood. · ID Following | **Psychiatric** Calm and cooperative. |
| **OBJECTIVE** |
| **Weight 133 lbs BMI 22.86** | **Temp 96.1** | **BP 108/54** |
| **Height 5’4”** | **Pulse 84** | **Resp 17** |
| **PHYSICAL EXAMINATION** |
| **General Appearance** Patient with normal appearance. Currently sleeping, easy to arouse. Weakness, fatigue, weight loss. No distress noted. Denies pain or discomfort at the moment. |
| **Skin** Skin is intact, warm, dry, and adequate color. Normal skin turgor. Capillary refills < 3 seconds. |
| **HEENT** Head in normocephalic/atraumatic. Visual field full by confrontation. Conjunctiva pink, sclera white. Pupils 3 mm equally, round react to light and accommodation. EOM intact. No nose discharged noted. Fontal sinuses non-tender to palpation. No bleeding gum noted. Buccal mucosa dry, pink, and intact. Uvula midline, no exudate noted. No JVD noted. |
| **Cardiovascular** Currently NSR. No murmurs noted upon auscultation. Denies Chest Pain. |
| **Respiratory** Clear to auscultation bilaterally. Saturation 99-100 % on NC 4 L. |
| **Gastrointestinal** Abdomen hard, rounded, distended, tender to palpation, hypoactive bowel sounds noted. Right abdominal colostomy w/ stool output and pink stoma. PGJ tube in place. Midline incision with staples noted, open to air, no drainage. |
| **Breast** No lumps noted on palpation. Symmetrical. |
| **Genitourinary** No inguinal Hernias or CVA tenderness. Urine clear and yellow. Monitor I/O. |
| **Musculoskeletal** Pain with ambulation. Weaknesses. Limited ROM. No cyanosis or pedal edema. |
| **Neurological** AAOx2, self and place, partially to situation, disoriented to time. Speech clear, forgetful. Following commands. Able to move all extremities equally. Weakness BL upper and Lower extremities. Denies headache or dizziness. |
| **Psychiatric** Patient with noted depression and light anxiety. |
| **Lab Tests:** CBC, BMP, Aptt, PT/INR, blood cx |

| |
| — |
| |
| **Special Tests:** Surgical Consult, CT ABD w/o contrast, Xray-ABD (KUB) |
| **Diagnosis** |
| · Primary Diagnosis-  Constipation, Achalasia. o Differential Diagnoses **:** Colon perforation, Acute colonic Pseudo Obstruction, Ischemic Colitis. Sepsis. o **Plan:**  CT ABD w/o Contrast STAT, Chest Xray, Labs including Blood cultures  Medication: Continue Invanz, Levophed  Education: NPO status, Incentive Spirometer use.  Will place A-Line for invasive BP monitoring, Strict I/O · Referrals: Surgical Consult on board, ID Following. PT/OT  Follow-up for new cultures and CT scan STAT and general surgery recommendations. |
| **References** |

SOAP NOTE

**## MSNSoapNoteRubricElsaPreceptor.pdf**

SOAP NOTE RUBRIC

Criteria Points Competent Need Improvement Not Acceptable

Score

Subjective (35 points) Provides
complete, concise,
and accurate
information,
which is well
organized and
easy to
understand.

Provides most of the
pertinent
information, but is
not well organized
and/or is slightly
challenging to
understand. May be
missing pertinent
negative information
(e.g., patient
denies…).

Limited or no
summary of
pertinent
information, is
organized
poorly, contains
inaccurate
information,
and/or is
difficult to
understand.

Chief complaint 5 5 3 1
HPI 10 10 8 6
Relevant PMH & FH 5 5 3 1
ROS 10 10 8 6
Currents: Allergies,
Meds/OTCs, Tobacco,
Immunizations, Diet, Exercise,
Sleep

5 5 3 1

Objective (40 points) Provides
complete, concise,
and accurate
information,
which is well
organized and
easy to
understand.

Provides most of the
pertinent
information, but is
not well organized
and/or is slightly
challenging to
understand. May be
missing pertinent
negative information
(e.g., patient denies)

Limited or no
summary of
pertinent
information, is
organized
poorly, contains
inaccurate
information,
and/or is
difficult to
understand.

General survey (Describe the
state of the patient at the time
of the examination)

10 10 8 6

Vital signs
Height, Weight, BMI

10 10 8 6

Physical exam-systematic,
organized and thorough and
related to the reason of the visit

20 20 18 16

Diagnosis/ Differentials
Diagnosis (10 points)

Main diagnosis/
Differentials
Diagnosis is
supported by the
objective and
subjective
assessment and
rationale for
choosing the

Main diagnosis/
Differentials
Diagnosis is
supported by the
objective and
subjective assessment
but the rationale for
choosing the
diagnosis is not

Main diagnosis/
Differentials
Diagnosis is not
supported by
the objective
and subjective
assessment and
the rationale for
choosing the

SOAP NOTE RUBRIC

diagnosis is
supported by the
evidence

supported by the
evidence

diagnosis is not
supported by
the evidence

Diagnosis/(Assessment) 5 5 3 1
List of differentials supported
by S+O findings (5 points)
Must provide 3 differential
diagnoses with one citation
for each diagnosis.

5 5 3 1

Plan of care (10 Points) Complete and
appropriate plan
for the main
problem and
other active
problems.
Includes
pharmacologic
and/or non-
pharmacologic
and/or complete
sig components.

Mostly complete and
appropriate plan for
the main problem
and other active
problems. May be
missing appropriate
non-pharmacologic
treatments and/or sig
components.

Missing or
inappropriate
treatment plan
for the main
problem and
other active
problems.

Diagnostic
tests/therapies/medications

5 5 3 1

Follow-up/Pt. Education and
Health Promotion

5 5 3 1

References (5 Points) Provides a
complete and
appropriate list of
references that
are in APA
format.

References listed are
appropriate (i.e.
guidelines or
primary), but not
complete and some
may be missing. Not
APA formatted.

References
missing or very
limited.
References
listed are
inappropriate
(i.e. tertiary)
and/or not
relevant.

References 5 5 3 1
Total 100

Comment:

**## SoapNoteConstipatiion..docx**

| | | |
| — | — | — |
| **Patient Initials: RH** | **Pt. Encounter Number: 2-5** |
| **Date: 1/15/2025** | **Age: 81 y.o** | **Sex: Male** |
| **Allergies: NKA Advanced Directives: On File** |
| **SUBJECTIVE** |
| **CC:** _“I have abdominal pain and bloating, my abdomen feels tight, and I haven’t had a bowel movements for 7 days. I feels nauseous and I have vomited.”_ |
| **HPI:** 81 y/o Male with Hx of HTN, achalasia, dementia and chronic constipation. Patient presents with constipation with colonic dilation and cecal pneumatosis. Reports bloating and abdominal discomfort. No significant rectal bleeding or weight loss. On 1/14 RRT called due to hypotension and concerns for evolving sepsis. **_Onset:_** 7 days ago **_Location:_** 4 ABD Quadrants **_Duration:_** Continuous **_Characteristics:_** Burning, Sharp Pain **_Aggravating Factors:_** Eating. Laying Flat **_Relieving Factors:_** Eating small, simple seasoning meals. Antacids. **_Treatment:_** CT ABD Scan STAT ordered, Surgical team on board, labs CBC, BMP, Aptt, PT/INR, blood cx. Close monitoring in ICU. |
| **Current Medications:** Insulin, Pulmicort, Donepezil, Memantine, Trazadone, Labetalol, Pantoprazole, TPN, Lipids. |
| **PMH:** HTN, Achalasia Dementia, Chronic- constipation **Medication Intolerances: None** **Chronic Illnesses/Major traumas:** HTN, IDDM, Dementia, Constipation **Screening Hx/Immunizations Hx:** Up to Date, Influenza and Pneumococcal. **Hospitalizations/Surgeries:** 1/9 s/p initial Exploratory Laparotomy, decompression of colon, loop transverse colostomy, and placement of gastrostomy tube. |
| **Family History:** Father-61 years old died from Pneumonia. Mother-76 years old died from Asthma and HTN. |
| **Social History:** _Patient comes from nursing home. Denies Tabacco, alcohol or drug use in the past. Ambulatory assist, requires a walker. Fall precautions in place._ |
| **ROS** |
| **General** AAOx2, appears in discomfort, multimodal pain control due to distention and bloating. | **Cardiovascular** · Hemodynamic monitoring and management. · Titrate pressors to maintain MAP >65. · Levophed at 4 mcg, wean as tolerated. · Will place Arterial Line for invasive BP monitoring. |
| **Skin** Pale, Cold and Dry. | **Respiratory** · Pt continues Ertapenem for resistant Klebsiella PNA in blood · Maintain SpO2 >92 %. · Continue pulmonary toilet · Encourage use of I/S |
| **Eyes** Denies visual loss, blurred vision, or double vision. Denies history of cataracts or glaucoma. Uses glasses. | **Gastrointestinal** · NPO Status · Continue TPN, Lipids · Gi Px: Protonix · Continue ostomy care, monitor output · General Surgery Following. |
| **Ears** History of otitis externa. Denies recent infections, ear pain, or tinnitus. Hard of hearing. | **Genitourinary/Gynecological** No acute issues: Denies urinary urgency, frequency, dysuria, odorous urine, suprapubic pain. · Continue monitoring of renal function, I/O, and electrolytes. Replace PRN. |

| | | |
| — | — | — |
| | |
| **Nose/Mouth/Throat** Denies nasal pain, drainage, congestion, or other sinus issues. Denies throat pain or swelling. | **Musculoskeletal** ROM limited. Denies muscle pain. · PT/OT ordered · OOB to Chair |
| **Breast** Denies discharge, tenderness. No palpable mass during exam. | **Neurological** Awake and Alert. Hx of dementia. Continue Donepezil, Memantine, Trazadone. |
| **Heme/Lymph/Endo** · Insulin sliding Scale- for Blood Glucose <180 · Afebrile, leukocytosis · Pt continues Ertapenem for resistant Klebsiella PNA in blood. · ID Following | **Psychiatric** Calm and cooperative. |
| **OBJECTIVE** |
| **Weight 133 lbs BMI 22.86** | **Temp 96.1** | **BP 108/54** |
| **Height 5’4”** | **Pulse 84** | **Resp 17** |
| **PHYSICAL EXAMINATION** |
| **General Appearance** Patient with normal appearance. Currently sleeping, easy to arouse. Weakness, fatigue, weight loss. No distress noted. Denies pain or discomfort at the moment. |
| **Skin** Skin is intact, warm, dry, and adequate color. Normal skin turgor. Capillary refills < 3 seconds. |
| **HEENT** Head in normocephalic/atraumatic. Visual field full by confrontation. Conjunctiva pink, sclera white. Pupils 3 mm equally, round react to light and accommodation. EOM intact. No nose discharged noted. Fontal sinuses non-tender to palpation. No bleeding gum noted. Buccal mucosa dry, pink, and intact. Uvula midline, no exudate noted. No JVD noted. |
| **Cardiovascular** Currently NSR. No murmurs noted upon auscultation. Denies Chest Pain. |
| **Respiratory** Clear to auscultation bilaterally. Saturation 99-100 % on NC 4 L. |
| **Gastrointestinal** Abdomen hard, rounded, distended, tender to palpation, hypoactive bowel sounds noted. Right abdominal colostomy w/ stool output and pink stoma. PGJ tube in place. Midline incision with staples noted, open to air, no drainage. |
| **Breast** No lumps noted on palpation. Symmetrical. |
| **Genitourinary** No inguinal Hernias or CVA tenderness. Urine clear and yellow. Monitor I/O. |
| **Musculoskeletal** Pain with ambulation. Weaknesses. Limited ROM. No cyanosis or pedal edema. |
| **Neurological** AAOx2, self and place, partially to situation, disoriented to time. Speech clear, forgetful. Following commands. Able to move all extremities equally. Weakness BL upper and Lower extremities. Denies headache or dizziness. |
| **Psychiatric** Patient with noted depression and light anxiety. |
| **Lab Tests:** CBC, BMP, Aptt, PT/INR, blood cx |

| |
| — |
| |
| **Special Tests:** Surgical Consult, CT ABD w/o contrast, Xray-ABD (KUB) |
| **Diagnosis** |
| · Primary Diagnosis-  Constipation, Achalasia. o Differential Diagnoses **:** Colon perforation, Acute colonic Pseudo Obstruction, Ischemic Colitis. Sepsis. o **Plan:**  CT ABD w/o Contrast STAT, Chest Xray, Labs including Blood cultures  Medication: Continue Invanz, Levophed  Education: NPO status, Incentive Spirometer use.  Will place A-Line for invasive BP monitoring, Strict I/O · Referrals: Surgical Consult on board, ID Following. PT/OT  Follow-up for new cultures and CT scan STAT and general surgery recommendations. |
| **References** |

SOAP NOTE

**## MSNSoapNoteRubricElsaPreceptor.pdf**

SOAP NOTE RUBRIC

Criteria Points Competent Need Improvement Not Acceptable

Score

Subjective (35 points) Provides
complete, concise,
and accurate
information,
which is well
organized and
easy to
understand.

Provides most of the
pertinent
information, but is
not well organized
and/or is slightly
challenging to
understand. May be
missing pertinent
negative information
(e.g., patient
denies…).

Limited or no
summary of
pertinent
information, is
organized
poorly, contains
inaccurate
information,
and/or is
difficult to
understand.

Chief complaint 5 5 3 1
HPI 10 10 8 6
Relevant PMH & FH 5 5 3 1
ROS 10 10 8 6
Currents: Allergies,
Meds/OTCs, Tobacco,
Immunizations, Diet, Exercise,
Sleep

5 5 3 1

Objective (40 points) Provides
complete, concise,
and accurate
information,
which is well
organized and
easy to
understand.

Provides most of the
pertinent
information, but is
not well organized
and/or is slightly
challenging to
understand. May be
missing pertinent
negative information
(e.g., patient denies)

Limited or no
summary of
pertinent
information, is
organized
poorly, contains
inaccurate
information,
and/or is
difficult to
understand.

General survey (Describe the
state of the patient at the time
of the examination)

10 10 8 6

Vital signs
Height, Weight, BMI

10 10 8 6

Physical exam-systematic,
organized and thorough and
related to the reason of the visit

20 20 18 16

Diagnosis/ Differentials
Diagnosis (10 points)

Main diagnosis/
Differentials
Diagnosis is
supported by the
objective and
subjective
assessment and
rationale for
choosing the

Main diagnosis/
Differentials
Diagnosis is
supported by the
objective and
subjective assessment
but the rationale for
choosing the
diagnosis is not

Main diagnosis/
Differentials
Diagnosis is not
supported by
the objective
and subjective
assessment and
the rationale for
choosing the

SOAP NOTE RUBRIC

diagnosis is
supported by the
evidence

supported by the
evidence

diagnosis is not
supported by
the evidence

Diagnosis/(Assessment) 5 5 3 1
List of differentials supported
by S+O findings (5 points)
Must provide 3 differential
diagnoses with one citation
for each diagnosis.

5 5 3 1

Plan of care (10 Points) Complete and
appropriate plan
for the main
problem and
other active
problems.
Includes
pharmacologic
and/or non-
pharmacologic
and/or complete
sig components.

Mostly complete and
appropriate plan for
the main problem
and other active
problems. May be
missing appropriate
non-pharmacologic
treatments and/or sig
components.

Missing or
inappropriate
treatment plan
for the main
problem and
other active
problems.

Diagnostic
tests/therapies/medications

5 5 3 1

Follow-up/Pt. Education and
Health Promotion

5 5 3 1

References (5 Points) Provides a
complete and
appropriate list of
references that
are in APA
format.

References listed are
appropriate (i.e.
guidelines or
primary), but not
complete and some
may be missing. Not
APA formatted.

References
missing or very
limited.
References
listed are
inappropriate
(i.e. tertiary)
and/or not
relevant.

References 5 5 3 1
Total 100

Comment:

**## SoapNoteConstipatiion..docx**

| | | |
| — | — | — |
| **Patient Initials: RH** | **Pt. Encounter Number: 2-5** |
| **Date: 1/15/2025** | **Age: 81 y.o** | **Sex: Male** |
| **Allergies: NKA Advanced Directives: On File** |
| **SUBJECTIVE** |
| **CC:** _“I have abdominal pain and bloating, my abdomen feels tight, and I haven’t had a bowel movements for 7 days. I feels nauseous and I have vomited.”_ |
| **HPI:** 81 y/o Male with Hx of HTN, achalasia, dementia and chronic constipation. Patient presents with constipation with colonic dilation and cecal pneumatosis. Reports bloating and abdominal discomfort. No significant rectal bleeding or weight loss. On 1/14 RRT called due to hypotension and concerns for evolving sepsis. **_Onset:_** 7 days ago **_Location:_** 4 ABD Quadrants **_Duration:_** Continuous **_Characteristics:_** Burning, Sharp Pain **_Aggravating Factors:_** Eating. Laying Flat **_Relieving Factors:_** Eating small, simple seasoning meals. Antacids. **_Treatment:_** CT ABD Scan STAT ordered, Surgical team on board, labs CBC, BMP, Aptt, PT/INR, blood cx. Close monitoring in ICU. |
| **Current Medications:** Insulin, Pulmicort, Donepezil, Memantine, Trazadone, Labetalol, Pantoprazole, TPN, Lipids. |
| **PMH:** HTN, Achalasia Dementia, Chronic- constipation **Medication Intolerances: None** **Chronic Illnesses/Major traumas:** HTN, IDDM, Dementia, Constipation **Screening Hx/Immunizations Hx:** Up to Date, Influenza and Pneumococcal. **Hospitalizations/Surgeries:** 1/9 s/p initial Exploratory Laparotomy, decompression of colon, loop transverse colostomy, and placement of gastrostomy tube. |
| **Family History:** Father-61 years old died from Pneumonia. Mother-76 years old died from Asthma and HTN. |
| **Social History:** _Patient comes from nursing home. Denies Tabacco, alcohol or drug use in the past. Ambulatory assist, requires a walker. Fall precautions in place._ |
| **ROS** |
| **General** AAOx2, appears in discomfort, multimodal pain control due to distention and bloating. | **Cardiovascular** · Hemodynamic monitoring and management. · Titrate pressors to maintain MAP >65. · Levophed at 4 mcg, wean as tolerated. · Will place Arterial Line for invasive BP monitoring. |
| **Skin** Pale, Cold and Dry. | **Respiratory** · Pt continues Ertapenem for resistant Klebsiella PNA in blood · Maintain SpO2 >92 %. · Continue pulmonary toilet · Encourage use of I/S |
| **Eyes** Denies visual loss, blurred vision, or double vision. Denies history of cataracts or glaucoma. Uses glasses. | **Gastrointestinal** · NPO Status · Continue TPN, Lipids · Gi Px: Protonix · Continue ostomy care, monitor output · General Surgery Following. |
| **Ears** History of otitis externa. Denies recent infections, ear pain, or tinnitus. Hard of hearing. | **Genitourinary/Gynecological** No acute issues: Denies urinary urgency, frequency, dysuria, odorous urine, suprapubic pain. · Continue monitoring of renal function, I/O, and electrolytes. Replace PRN. |

| | | |
| — | — | — |
| | |
| **Nose/Mouth/Throat** Denies nasal pain, drainage, congestion, or other sinus issues. Denies throat pain or swelling. | **Musculoskeletal** ROM limited. Denies muscle pain. · PT/OT ordered · OOB to Chair |
| **Breast** Denies discharge, tenderness. No palpable mass during exam. | **Neurological** Awake and Alert. Hx of dementia. Continue Donepezil, Memantine, Trazadone. |
| **Heme/Lymph/Endo** · Insulin sliding Scale- for Blood Glucose <180 · Afebrile, leukocytosis · Pt continues Ertapenem for resistant Klebsiella PNA in blood. · ID Following | **Psychiatric** Calm and cooperative. |
| **OBJECTIVE** |
| **Weight 133 lbs BMI 22.86** | **Temp 96.1** | **BP 108/54** |
| **Height 5’4”** | **Pulse 84** | **Resp 17** |
| **PHYSICAL EXAMINATION** |
| **General Appearance** Patient with normal appearance. Currently sleeping, easy to arouse. Weakness, fatigue, weight loss. No distress noted. Denies pain or discomfort at the moment. |
| **Skin** Skin is intact, warm, dry, and adequate color. Normal skin turgor. Capillary refills < 3 seconds. |
| **HEENT** Head in normocephalic/atraumatic. Visual field full by confrontation. Conjunctiva pink, sclera white. Pupils 3 mm equally, round react to light and accommodation. EOM intact. No nose discharged noted. Fontal sinuses non-tender to palpation. No bleeding gum noted. Buccal mucosa dry, pink, and intact. Uvula midline, no exudate noted. No JVD noted. |
| **Cardiovascular** Currently NSR. No murmurs noted upon auscultation. Denies Chest Pain. |
| **Respiratory** Clear to auscultation bilaterally. Saturation 99-100 % on NC 4 L. |
| **Gastrointestinal** Abdomen hard, rounded, distended, tender to palpation, hypoactive bowel sounds noted. Right abdominal colostomy w/ stool output and pink stoma. PGJ tube in place. Midline incision with staples noted, open to air, no drainage. |
| **Breast** No lumps noted on palpation. Symmetrical. |
| **Genitourinary** No inguinal Hernias or CVA tenderness. Urine clear and yellow. Monitor I/O. |
| **Musculoskeletal** Pain with ambulation. Weaknesses. Limited ROM. No cyanosis or pedal edema. |
| **Neurological** AAOx2, self and place, partially to situation, disoriented to time. Speech clear, forgetful. Following commands. Able to move all extremities equally. Weakness BL upper and Lower extremities. Denies headache or dizziness. |
| **Psychiatric** Patient with noted depression and light anxiety. |
| **Lab Tests:** CBC, BMP, Aptt, PT/INR, blood cx |

| |
| — |
| |
| **Special Tests:** Surgical Consult, CT ABD w/o contrast, Xray-ABD (KUB) |
| **Diagnosis** |
| · Primary Diagnosis-  Constipation, Achalasia. o Differential Diagnoses **:** Colon perforation, Acute colonic Pseudo Obstruction, Ischemic Colitis. Sepsis. o **Plan:**  CT ABD w/o Contrast STAT, Chest Xray, Labs including Blood cultures  Medication: Continue Invanz, Levophed  Education: NPO status, Incentive Spirometer use.  Will place A-Line for invasive BP monitoring, Strict I/O · Referrals: Surgical Consult on board, ID Following. PT/OT  Follow-up for new cultures and CT scan STAT and general surgery recommendations. |
| **References** |

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