1. Select a patient” (friend or family member) on whom to perform

1. Select a “patient” (friend or family member) on whom to
perform a complete H&P.
2. NOTE: DO NOT USE REAL NAMES OR INITIALS OR
OTHERWISE IDENTIFY YOUR “PATIENT.” FAILURE TO
MAINTAIN PRIVACY WILL RESULT IN A FAILING SCORE.
3. Using the format specified below, write a 2 page SOAP note
on your “patient.” The HPI should be presented in a
paragraph, and the rest of the data including the ROS should be
presented in a list format.
4. Collect only the information that is pertinent to the chief
complaint of the patient to include in your SOAP note. Aim for
a single page using normal margins and format.
5. The SOAP Note must contain all required elements as
outlined in the rubric below.
6. You must self-score your SOAP note using the rubric and
attach it to the assignment.
Criteria Ratings Points
Thread
Content
50 to >46.0 pts
Advanced
47 to 50 points All key
components of the
Discussion Board Forum
prompt are answered in
the thread. Major points

are supported by all of the
following: *Reading &
Study materials; *Pertinent,
conceptual, or personal
examples; *Thoughtful
analysis (considering
assumptions, analyzing
implications, and
comparing/contrasting
concepts); and *Source
citations in current APA
format, include the
required 7 or more from
personal research, the
course readings, and the
integration of 1 biblical
principle.
46 to >43.0 pts
Proficient
44 to 46 points Some key
components of the
Discussion Board Forum
prompt are answered in the
thread. Major points are
supported by some of the
following): *Reading &
implications, and

format, include the required
7 or more from personal
research, the course
readings, and the
principle.
43 to >0.0 pts
Developing
Minimal key components of
the Discussion Board
Forum prompt are
answered in the thread.
Major points are supported
by some or none of the
following: *Reading &
implications, and
format, include the required
7 or more from personal
research, the course
readings, and the
principle

0 pts
Not
Present
50 pts
Replies
Content
41 to >39.0 pts
Advanced
Contribution made to
discussion with each reply
expounding on the thread.
Major points are supported
by all of the following:
*Reading & Study
materials; *Pertinent,
implications, and
concepts); and *Three
peer-reviewed source
format, and the integration
of 1 biblical principle.
39 to >35.0 pts
Proficient

Marginal contribution made
to discussion with each
reply slightly expounding on
the thread. Major points are
supported by some of the
following): *Reading &
implications, and
35 to >0.0 pts
Developing
Minimal contribution made
to discussion with each
reply slightly expounding
on the thread. Major points
are supported by some or
none of the following:
*Reading & Study
materials; *Pertinent,

implications, and
0 pts
Not
Present
41 pts
Discussion Grading Rubric | BUSI735_B02_202230
Criteria Ratings Points
Thread:
Grammar
and
Spelling,
APA
formatting
5 to >4.0 pts
Advanced
Proper spelling, grammar,
and APA format are used.
4 to >3.0 pts

Proficient
Marginal spelling, grammar,
and APA format are used
(1-3 errors are present).
3 to >0.0 pts
Developing
Minimal spelling, grammar,
0 pts
Not
Present
Not
present.
5 pts
Thread:
Word
Count
5 to >4.0 pts
Advanced
Required word count
(2,100-2,200 words) is
met.

4 to >3.0 pts
Proficient
Required word count
(2,100-2,200 words) is not
marginally met (1,000
words).
3 to >0.0 pts
Developing
Required word count
(2,100-2,200 words) is not
met (499 words or less).
0 pts
Not
Present
Not
present.
5 pts
Replies:
Grammar
and
Spelling,
APA
formatting
10 to >9.0 pts

Advanced
Proper spelling, grammar,
and APA format are used.
9 to >8.0 pts
Proficient
Marginal spelling, grammar,
8 to >0.0 pts
Developing
Minimal spelling, grammar,
0 pts
Not
Present
Not
present.
10 pts
Replies:
Word
Count

19 to >17.0 pts
Advanced
Both replies are present
and contain a sufficient
word count (600-700 words
each).
17 to >16.0 pts
Proficient
Replies submitted, but 1
reply submitted with
insufficient word count
and/or only 1 reply has
been submitted.
16 to >0.0 pts
Developing
Both replies submitted with
insufficient word counts
and/or only 1 reply has
been submitted.
0 pts
Not
Present
Not
present.

19 pts
Total Points: 130
Discussion Grading Rubric | BUSI735_B02_202230
2000 WORDS
Choose two ways that organizations have changed over the
years and provide a past to current summary, integrating theory
and personal perspectives. Integrate at least one biblical
principle.
Your discussion should include any of the previous chapter
concepts, including the readings from this week.
Subjective Data
· Biographic Data:– Age/race/gender, date, occupation,
language/communication needs.
· Source – and reliability
· Chief Complaint (reason for seeking care)- make every
attempt to use patient’s own words.
· History of Present Illness (HPI)- complete, clear,
chronological account of events prompting patient to seek care.
Use OLDCARTS or PQRST to gather data but do not include
acronym in HPI. Document in paragraph format.
· Past Medical History (PMH)- childhood, adult illnesses,
serious illnesses/hospitalizations, obstetric hx, Immunizations,
last exam
· Allergies, medication, food, environmental
· Medications- Rx, OTC, herbal, etc.
· Family History- write a genogram diagram or outline; age,
health, age, and cause of death of each family member going
back three generations.
· Personal and Social History- interests, support systems,
occupation, highest level of education, job history, financial
situation, spiritual beliefs, lifestyle, alternative health care

practices, sexual and obstetric history.
· Review of Systems (ROS)- series of questions from head to
toe. Must be in the following order – include health promotion
practices:
· General Survey
· Integumentary
· Head, Eyes, Ears, Nose, and Throat
· Neck/thyroid
· Breasts and axillary lymph nodes
· Respiratory
· Cardiovascular
· Peripheral vascular
· Gastrointestinal
· Genitourinary
· Genital/Reproductive system
· Sexual health
· Musculoskeletal
· Neurological (must include reflexes on PE)
· Hematologic
· Endocrine
· Functional assessment - include activities of daily living
· Self-esteem/self-concept
· Activity/exercise
· Sleep/rest/nutrition, include
· Nutritional status assessment- identify if patient is at risk for
malnutrition or over nutrition
· Interpersonal relationships
· Spiritual resources
· Coping and stress management
· Personal habits – alcohol, tobacco, street drugs
· Environment/Hazards
· Intimate partner violence
· Occupational health
· Perception of health
· Developmental Competence – children, pregnant women, older
adult

Objective data
· Physical Examination (PE)
· General Survey
· Integumentary
· Head, Eyes, Ears, Nose, and Throat
· Neck/thyroid
· Breasts and axillary lymph nodes
· Respiratory
· Cardiovascular
· Peripheral vascular
· Gastrointestinal
· Genitourinary
· Genital/Reproductive system
· Sexual health
· Musculoskeletal
· Neurological (must include reflexes on PE)
· Hematologic
· Endocrine
Assessment
· Diagnosis with rationale
· Differential diagnosis with rationales
Plan
· Dx plan – include diagnostic tests needed (lab, x-ray, etc.)
· Tx plan – include recommended treatment – cite national
guidelines
· Patient education – including specific medication teaching
· Referral/Follow up
· Health Maintenance – include health promotion
recommendations from AHRQ (ePSS app) according to
age/gender/conditions
SOAP NOTE RUBRIC
0-5
points

6-10
points
11-15
points
16-20
points
21-25
points
Student
Score
SUBJ
Data is not organized. Objective is mixed into the subjective
data.
Data is not well organized. The complete pre-conceived
differential considered is incomplete. Data is missing.
Data is well organized with C/C, OLDCART, pertinent
negatives, and pertinent positives. It is clear to the reader that
information is gathered to include/exclude options in the
differential. Too much extraneous data
Data is well organized with C/C, OLDCART, pertinent
negatives, and pertinent positives. Little extraneous data may be
present.
Complete, concise, relevant without extraneous data. All data
needed to support differential is present with no extraneous
data.
OBJ
Subjective data is included.
Not all relevant exams were done.
All relevant exams were done but not thoroughly.
All relevant exams were done thoroughly but extraneous exams
were also done.
Complete, concise, well-organized and well-written.
DDX
No assessment provided.

Assessment present but mixed with other problems that are not
reflective of S/0. Appears to be preceptor's diagnosis.
Assessment reflects information in S/O data but does not
include correct differential.
Each problem identified has a differential that is reflected in
S/O. Differential/problems are not prioritized correctly.
Assessment and prioritized differential accurate and supported.
Demonstrates exceptional critical thinking.
PLAN
No Plan provided
Plan present but does not address all problems identified.
Appears to be preceptor’s plan.
Plan addresses all problems but some interventions are not
evidence-based.
Plan is organized but fails to address any of: barriers to
compliance needs for education plan for preventive complete
plan for follow up.
Plan is complete prioritized, and demonstrates exceptional
critical thinking. Counseling on despair was accomplished.
Total Score:

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