Mennonite
At
Family Nurse Practitioner Sequence
General Guidelines for SOAP Notes
· Hand written notes must be legible to faculty (note may be turned back to student solely on basis of legibility for rewriting).
· Rewrites of notes must also be in legible format.
· Use of agency/clinic format is acceptable (copy is made to turn into faculty with patient name and identifiers deleted). Some agency formats are not complete enough to qualify as a passing SOAP note. These may require extra information to be added that your preceptor may not require in your documentation.
· SOAP notes not on agency forms must be typed.
· Notes may be e-mailed to faculty (but note that scanned agency forms are frequently not legible therefore not acceptable).
· Different items under “A” and “P” must be clearly differentiated (numbered or bulleted) so that each diagnosis has a clear plan.
· More detail is generally needed in notes regarding plan/ patient education/ follow-up than preceptors may require.
· Abnormals in HPI and physical assessments must then addressed in “A” and “P” of note, even if just to monitor/recheck at a later date.
· Any item in “P” (medication, lab, education, etc.,) must have a corresponding item in “A”.
Regarding SOAP notes: As noted on the course syllabus, notes will be graded as "pass/fail" with 1% of the grade given for each satisfactory note. This percentage will only be awarded for SOAP notes approved by dates specified on the course assignments page. For example, a student who has 2 SOAP notes approved by the first specified deadline will receive credit equivalent to 2% of the 10% SOAP note points. If no SOAP notes have been approved by the deadline, the student will lose the opportunity for those points.