SOAP NOTE
Assignment Instructions: ?”Your Choice: Assignment: SOAP Note Assignment
General Information
The SOAP Note assignment is intended to give you practice writing SOAP notes from actual patient data. You will be provided with a prenatal record reflecting care
provided to a woman at her first prenatal visit. You will use that data to craft a SOAP Note that you would write in her chart. The assignment is designed to give you
an opportunity to both show that you know what information is important to reflect in your chart SOAP note as well as to give you practice writing in SOAP note format.
This assignment is an individual assignment. You are able to use course materials but you are not to discuss your assignment with any other people. If you have
qustions about your assignment, you may contact the course coordinator directly. Resubmissions are not available for this assignment.
Completing your SOAP note
HERE is the prenatal record reflecting the data from the first new OB visit. You are to use the SOAP Note Template to organize your SOAP Note reflecting the data from
this chart.
HERE is the template for writing your SOAP Note. It is a Word document, and you may type your note directly onto this document. Remember that your SOAP note needs to
be “chart ready”, so don’t forget to delete any instructions, notes, etc. from this document before turning it in.
When writing your SOAP note, please remember these important things:
1. You don’t need to write in full sentences. It is best to use phrases. Be concise so that you and your partners can find the necessary information quickly when
reviewing the chart. Don’t compromise information, just refrain from writing an essay!
2. You may think in “outline” format when constructing your soap note (some people find this to be an effective way of thinking), but it is best for your finished note
to report the important and pertinent data in phrases, more like “bullet-points” than an outline.
3. You do not need to list all components of your teaching in your plan. For example, if you provide diet/nutrition teaching during your visit, you may simply say
“Diet/nutrition discussed” in your plan. You do not need to list the specific number of servings, where to get the nutrients, why they are important, etc. in your
plan. It is assumed that you (the midwife) know what kind of teaching to provide to women about nutrition in pregnancy and that this is what was discussed.
4. The template is organized according to templates you have used in prior FNU courses. By using this format, you are less likely to forget to include important items.
You do not need to repeat things twice in your plan (for example, if you provide her with a medication in the RX section, you don’t need to discuss the education you
gave her about how to take that medication in the ED section- you can just list the medication and write “with instructions” after it in the RX section). If a topic
seems appropriate to include in two different sections, choose which section to put it in and include all the pertinent information there.
Turning in your SOAP note
You must place a final and complete version of your SOAP note as a file attachment in the SOAP Note drop box. Rough drafts, additions, deletions and other changes will
not be accepted after you have submitted your assignment. The first version uploaded will be graded, so make sure it is your final and correct version. Please follow
Frontier file naming guidelines.
You may turn in your SOAP note at any time prior to the due date, but be aware that you will need to know material from the entire course to successfully complete this
assignment.
The SOAP Note Assignment is due as indicated on the syllabus and in the course calendar. The time is determined by submission time in Angel (i.e. 12:01 is late). If
you submit an assignment later than this time, 2 points are deducted every day the assignment is late. There is no revision opportunity for SOAP Note assignments.
Helpful Information
You will find Slides for our BBC on Writing SOAP Notes HERE. The BBC is accessible in the Media Folder in the Blackbaord Collaborate sessions page and in the Course
Forum.
You can access an important presentation on making an assessment list here.
Grading Rubric for SOAP Note Assignment
Dimension 10 8 6 4 0 Total
Content Meets all criteria Meets most criteria Meets some criteria Meets minimal criteria Does not meet criteria 40
Subjective:
• Documents appropriate and complete subjective assessment data
• Does not include non-essential data 10
Objective
• Lists appropriate and complete data for each system.
• Does not include non-essential data 10
Assessment
• Identifies appropriate and complete Assessment list based on subjective and objective data.
• Assessment list reflects assessment, not subjective or objective data. 10
Plan
• Is based on analysis of the data.
• Reflects assessment list contents.
• Reflects individual patient situation
• Includes complete documentation of medications, if appropriate.
• Includes treatments, if appropriate.
• Includes diagnostic tests, if appropriate
• Includes education when appropriate
• Includes follow-up/ referral, if appropriate 10
Dimension 10 8 6 4 0 Total
Quality Data is organized in a concise, logical format. SOAP note is “chart ready”. Data is organized in a somewhat concise, logical format. SOAP note is “chart
ready”. Data is organized in a minimally concise, logical format. SOAP note is “chart ready”. Data is organized in a minimally concise, logical format. SOAP note is
not “chart ready”. Data is not organized in a concise, logical format. SOAP note is not “chart ready”. 10
Quality of note meets following criteria:
• Organized in a concise, logical format
• SOAP note is “chart ready”.
Total Points 50
