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The goal of this assignment is to practice writing a SOAP Note for a sick or episodic visit related to the focus system(s) reviewed in the previous week’s learning materials- CARPAL TUNNEL SYNDROME . Review the SOAP Note Rubric. Use a case from the previous week’s discussion or patient from your video submission or clinical practicum experience (adding content as needed to represent abnormal findings). RUBRIC: [SOAP Note Rubric] – 100 Subjective – 25% Information about the patient (3 points) Chief Complaint (1 point) story of Presenting Illness (8 points) Review of Focus System(s) (5 points) Medications/Allergies (3 points) story (5 points) Patient described in appropriate detail Concise and clear chief complaint as described by patient HPI includes all components with appropriate detail Comprehensive review of focus system(s) includes pertinent negatives Name, dose, route, and frequency of prescribed and over-the-counter medications noted, including compliance; Allergies to medications and reaction noted Comprehensive health history is appropriate to reason for visit and includes pertinent negatives Patient described in appropriate detail Concise and clear chief complaint as described by patient HPI missing minor detail Comprehensive review of focus system(s) Name, dose, route, and frequency of prescribed and over-the-counter medications noted, including compliance; Allergies to medications and reaction noted Comprehensive health history is appropriate to reason for visit 1 detail missed in patient description Chief complaint as described by patient, may not be concise or clear HPI missing 1 component or significant detail Review of focus system missing 1-2 components Medication history missing 1-2 components Health history not appropriate for reason for visit or missing 1-2 components >2 details missed in patient description Chief complaint not identified, concise, or clear HPI missing >2 components and significant detail Review of focus system(s) missing >3 components Medication history missing >3 components Health history missing >3 components Objective – 30% Physical exam includes appropriate areas for Chief Complaint, story of Presenting Illness, and Review of Systems (20 points) Appropriate techniques of examination used to identify pertinent findings (10 points)Appropriate areas and systems included in physical as

sessment Comprehensive techniques of observation, palpation, percussion, and auscultation noted including special assessments as appropriate Missing 1 expected area of assessment Appropriate techniques of examination used but special assessment technique missed Missing 2 expected areas of assessment One basic technique of examination missed Missing >3 expected areas of assessment >2 techniques of examination missed Assessment – 20% Differential diagnoses are supported by subjective and objective findings (15 points) Scholarly resources support differential diagnoses (5 points)Three differential diagnoses are supported by findings and include worst case scenario Rationale for differential diagnoses provided by scholarly resources Three differential diagnoses include worst case scenario but one diagnosis may not be fully supported by findings Rationale for differential diagnoses provided by scholarly resources Differential diagnoses may or may not include worst case scenario and 2 differential diagnoses not supported by findings Rationale for all differential diagnoses not provided by scholarly resources <3 differential diagnoses identified, or differential diagnoses not supported by findings and do not include worst case scenario Scholarly resources not provided or do not support differential diagnoses Plan – 15% Comprehensive plan to address likely differential diagnosis includes (9 points) Plan is supported by appropriate and current practice guidelines (6 points)Comprehensive plan includes all components Appropriate and current guidelines cited Plan missing 1 of the identified components Appropriate and current guidelines cited Plan missing 2 of the identified components Guidelines are not current or appropriate for identified problem Plan missing >3 of the identified components Guidelines for plan not cited Documentation – 10% Documentation follows SOAP template, is logical, and in correct format (10 points)Logical and systematic organization of data Correct terminology, spelling, and grammar Scholarly resources noted in correct APA format Logical and systematic organization of data Terminology, spelling, grammar or format errors (1-3) Minor errors in organization of data Terminology, spelling, grammar, or format errors (4-5) Disorganized flow of data Terminology, spelling, grammar or format errors (>5) Total Points