Please note this is an analysis of a soap note. Please make sure to go directly by the grading rubric. Do not deviate from the grading rubric! Please answer all requirements of the grading rubric.
Genitourinary Assessment
CC: Increased frequency and pain with urination
HPI:
T.S. is a 32-year-old woman who reports that for the past two days, she has dysuria, frequency, and urgency. Has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months.
Medical History:
None
Surgical History:
Tonsillectomy in 2001
Appendectomy in 2020
Review of Systems:
General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
Abdominal: Denies nausea and vomiting. No appetite
Objective
VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.
Pelvic Exam:
mild tenderness to palpation in the suprapubic area
bimanual pelvic examination reveals a normal-sized uterus and adnexae
no adnexal tenderness.
No vaginal discharge is noted.
The cervix appears normal.
Diagnostics: Urinalysis, STI testing, Papsmear
Assessment:
UTI
STI
The Lab Assignment
Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by subjective and objective information? Why or why not?
Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
CriteriaRatingsPts
This criterion is linked to a Learning OutcomeWith regard to the SOAP note case study provided and using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature: Analyze the subjective portion of the note. List additional information that should be included in the documentation.
12 to >9.0 pts
Excellent
The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation.
9 to >6.0 pts
Good
The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.
6 to >3.0 pts
Fair
The response vaguely analyzes the subjective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.
3 to >0 pts
Poor
The response inaccurately analyzes the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
12 pts
This criterion is linked to a Learning Outcome Analyze the objective portion of the note. List additional information that should be included in the documentation.
12 to >9.0 pts
Excellent
The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation.
9 to >6.0 pts
Good
The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation.
6 to >3.0 pts
Fair
The response vaguely analyzes the objective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.
3 to >0 pts
Poor
The response inaccurately analyzes the objective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
12 pts
This criterion is linked to a Learning Outcome Is the assessment supported by the subjective and objective information? Why or why not?
16 to >13.0 pts
Excellent
The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.
13 to >10.0 pts
Good
The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a clear explanation.
10 to >7.0 pts
Fair
The response vaguely identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation.
7 to >0 pts
Poor
The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.
16 pts
This criterion is linked to a Learning Outcome What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
20 to >17.0 pts
Excellent
The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis.
17 to >14.0 pts
Good
The response accurately describes appropriate diagnostic tests for the case and explains how the test results would be used to make a diagnosis.
14 to >11.0 pts
Fair
The response vaguely and/or with some inaccuracy describes appropriate diagnostic tests for the case and vaguely and/or with some inaccuracy explains how the test results would be used to make a diagnosis.
11 to >0 pts
Poor
The response inaccurately describes appropriate diagnostic tests for the case, with an inaccurate or missing explanation of how the test results would be used to make a diagnosis.
20 pts
This criterion is linked to a Learning Outcome Would you reject or accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
25 to >22.0 pts
Excellent
The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature.
22 to >19.0 pts
Good
The response states whether to accept or reject the current diagnosis, with an accurate explanation of sound reasoning. The response accurately identifies three conditions as a differential diagnosis, with reasoning that is explained using three different references from current evidence-based literature.
19 to >16.0 pts
Fair
The response states whether to accept or reject the current diagnosis, with a vague explanation of the reasoning. The response identifies two to three conditions as a differential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three or fewer references from current evidence-based literature.
16 to >0 pts
Poor
The response inaccurately states or is missing a statement of whether to accept or reject the current diagnosis, with an explanation that is inaccurate and/or missing. The response identifies three or fewer conditions as a differential diagnosis, with reasoning that is missing or explained inaccurately using two or fewer references from current evidence-based literature.
25 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 to >4.0 pts
Excellent
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
4 to >3.0 pts
Good
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
3 to >2.0 pts
Fair
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.
2 to >0 pts
Poor
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided. 5 pts This criterion is linked to a Learning OutcomeWritten Expression and Formatting - English writing standards: Correct grammar, mechanics, and proper punctuation 5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.
4 to >3.0 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
3 to >2.0 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.
2 to >0 pts
Poor
Contains many (= 5) grammar, spelling, and punctuation errors that interfere with the readers understanding.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
5 to >4.0 pts
Excellent
Uses correct APA format with no errors.
4 to >3.0 pts
Good
Contains a few (1 or 2) APA format errors.
3 to >2.0 pts
Fair
Contains several (3 or 4) APA format errors.
2 to >0 pts
Poor
Contains many (= 5) APA format errors.
5 pts
Total Points: 100
