<p><strong>Primarily check APA and Grammar, thanks</strong><br /><br /><br /><br />TEXAS WOMAN&rsquo;S UNIVERSITY</p>
<p>COLLEGE OF NURSING</p>
<p>NURS 5644 ADVANCED HEALTH ASSESSMENT/DIFFERENTIAL DIAGNOSIS</p>
<p>FOCUSED SOAP EVALUATION CRITERIA</p>
<p>Name:_____________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</p>
<p>&nbsp;</p>
<p>Date:______________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Faculty:__________________</p>
<p>&nbsp;</p>
<p>0 = incomplete or omitted</p>
<p>1 = &lt; 50% of required information is collected and documented</p>
<p>2 = 50% of data is present</p>
<p>3 = 75% of data is present</p>
<p>4 = Thorough and complete with no missing data</p>
<p>&nbsp;</p>
<p><strong>Patient Identifying Criteria:</strong></p>
<p>Narrative to include patient&rsquo;s initials, age, race, marital status, education, others accompanying patient, clinic, insurer.</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</p>
<table>
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<p>S-O-A CONTENT</p>
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<p>GRADING SCALE</p>
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<p><strong>Subjective (S)</strong></p>
<p><em>Chief complaint (CC)</em> in patient&rsquo;s own words</p>
<p>&nbsp;</p>
</td>
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<p>&nbsp;</p>
<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4</p>
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<p><strong><em>History of Present Illness (HPI)</em></strong></p>
<ol>
<li>Onset (sudden or insidious)</li>
<li>Location (radiation over time)</li>
<li>Duration (how long has it been a problem for patient)</li>
<li>Character (burning stabbing, associated factors like nausea, vomiting, diarrhea, rash, etc.)</li>
<li>Aggravating factors (food, voiding, defecation, heat cold, motion, environmental)</li>
<li>Relieving factors (OTC, voiding, defecation, food, heat cold, motion, environmental)</li>
<li>Timing (continuous, intermittent, cyclic)</li>
<li>Severity (impact on activities of daily living, pain scale as indicated)</li>
</ol></td>
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<p>&nbsp;</p>
<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4</p>
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<p><strong><em>Past Medical History </em></strong></p>
<ol>
<li>Medications (prescriptions, OTCs, CAMs)</li>
<li>Allergies (medications, food, environmental exposures)</li>
<li>Major adult illnesses (physiological, psych)</li>
<li>Childhood illnesses</li>
<li>Serious accidents/injuries</li>
<li>Surgeries</li>
<li>Hospitalizations</li>
<li>Blood transfusions</li>
<li>OB/GYN history, (age at menarche, number of pregnancies, deliveries, types of deliveries, STIs)</li>
</ol></td>
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<p>&nbsp;</p>
<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4</p>
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<p><strong><em>Family History</em></strong></p>
<p>Parents, maternal and paternal grandparents, siblings, &amp; children</p>
</td>
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<p>&nbsp;</p>
<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4</p>
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<p><strong><em>Previous Health Care/Health Promotion</em></strong></p>
<p>Health Maintenance Practices:</p>
<ol>
<li>Last Physical Exam&nbsp;&nbsp;</li>
<li>Recent Screening tests (Pap, Mammogram, Prostate, Vision, Dental) Provide date and results.</li>
<li>Self-screening/monitoring (skin, vulvar, breast, testicular, etc.)</li>
<li>Nutrition</li>
<li>Exercise</li>
<li>STI protection</li>
<li>Personal safety in the home (use of seat belts, sports safety, firearms, medications, toxic substances, smoke detectors)</li>
</ol></td>
<td width="256">
<p>&nbsp;</p>
<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4</p>
</td>
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<p><strong><em>Social History</em></strong></p>
<ol>
<li>Environment&nbsp;&nbsp;&nbsp;&nbsp;</li>
<li>Home living conditions/neighborhood type</li>
<li>Occupation</li>
<li>Travel/exposures</li>
<li>Economic resources/concerns</li>
<li>Military record</li>
<li>Religious or cultural considerations</li>
<li>Sexual history</li>
<li>Hobbies/interests</li>
<li>Social support network</li>
<li>Habits (alcohol, drugs, tobacco, caffeine, illegal substances, (use of vitamins, caffeine, herbs, other dietary supplements)</li>
</ol></td>
<td width="256">
<p>&nbsp;</p>
<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4</p>
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<p><strong><em>Review of Systems (ROS) systems pertinent for presenting complaint</em></strong></p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; General</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; Skin</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; Head</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; Eyes</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; Ears</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; Nose</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; Throat and mouth</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; Neck&nbsp;&nbsp; &nbsp; &nbsp;</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; Breasts&nbsp;&nbsp;&nbsp;&nbsp;</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; CV</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; PV</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; Chest/Lungs&nbsp;&nbsp;</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; GI</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; GU (Female or Male)</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; Musculoskeletal</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; Neuro</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; Psych&nbsp;&nbsp; &nbsp; &nbsp;</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; Endocrine&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;</p>
<p>&nbsp;</p>
</td>
<td width="256">
<p>&nbsp;</p>
<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4</p>
</td>
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</tbody>
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<br />
<p>&nbsp;</p>
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<tbody>
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<p><strong>Objective (O)</strong></p>
<ol>
<li>&nbsp;General Survey</li>
<li>&nbsp;Vital signs (pain rating, if indicated)</li>
<li>&nbsp;Physical Exam of relevant systems in DETAIL</li>
<li>&nbsp;Diagnostic/lab, imaging results from today&rsquo;s patient encounter as well if pertinent to CC</li>
</ol></td>
<td width="256">
<p>&nbsp;</p>
<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4</p>
</td>
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<p><strong>Assessment (A)</strong></p>
<p>Differential Diagnoses</p>
<ol>
<li>List at least 3 differential diagnoses. Differential diagnosis with the greatest potential for morbidity or mortality should be listed first.</li>
<li>Rationale for ruling in/ruling out for differential diagnoses.</li>
<li>Provide references (narrative for rationale should be in APA 6<sup>th</sup> Ed. Format)</li>
</ol></td>
<td width="256">
<p>&nbsp;</p>
<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4</p>
<p>&nbsp;</p>
</td>
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<p><strong>Concluding Diagnosis </strong></p>
<ol>
<li>Concluding diagnosis fits the patient&rsquo;s H&amp;P (symptoms)</li>
<li>Discussed rationale for selecting concluding diagnosis</li>
</ol>
<p>(narrative for rationale should be in APA 6<sup>th</sup> Ed. Format)</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 4. &nbsp; &nbsp; Include ICD 10 code for concluding diagnosis</p>
</td>
<td width="256">
<p>&nbsp;</p>
<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1 &nbsp;&nbsp;&nbsp;2&nbsp;&nbsp; &nbsp; &nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4</p>
<p>&nbsp;</p>
</td>
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<p><strong>Health or Injury Risk Factors:</strong></p>
<p>e.g., unintended pregnancy, falls, domestic violence, STIs, Hep C/A, diabetes, cancer, injury, CVD</p>
<p>&nbsp;</p>
</td>
<td width="256">
<p>&nbsp;</p>
<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4</p>
<p>&nbsp;</p>
</td>
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<p><strong>Plan</strong></p>
<p>(Individualized and culturally appropriate)</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; Peds &ndash; always include anticipatory guidance.</p>
<p>&nbsp;&nbsp;&nbsp;&nbsp; Adults &ndash; Always include health maintenance.</p>
<p>Diagnostics - Tests, additional info needed</p>
<p>RX &ndash; Pharm, nonpharm (e.g., diet, exercise, complementary care)</p>
<p>Education &ndash; Teach/counsel</p>
<p>F/U&nbsp;&nbsp; and/or referral-when to RTC</p>
</td>
<td width="256">
<p>&nbsp;</p>
<p>&nbsp;</p>
<p>&nbsp;</p>
<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4</p>
<p>&nbsp;</p>
</td>
</tr>
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<p>Spelling, grammar and APA format for references</p>
<p>0= &gt; 8 errors</p>
<p>1= 3-7 errors</p>
<p>2= &lt; 3 errors</p>
</td>
<td width="256">
<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp;</p>
<p>&nbsp;</p>
<p>&nbsp;</p>
</td>
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</tbody>
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<p>Total Points = ____________ out of possible 50 points</p>
<p>Percentage = _____________</p>
<p>&nbsp;</p>
<p>The total possible score for each SOAP is 50 points. Minimum score for passing is 40 (80%).</p>
<p><strong>Comments:</strong></p>
<p>&nbsp;</p>