ENL1902F: SOAP Note Assignment (10%)
Objective:
Write one SOAP Note for each of the scenarios listed below.
Scenario 1:
A female adolescent arrives at your agency for an intake interview. She tells you that
her name is Monique, that she is 17 years old (she produces photo identification to
confirm her name and date of birth), and that she is ten weeks pregnant. Her hair is
a mess, greasy and bedraggled. She produces a note from a local clinic, signed by a
Dr. Booth, indicating that she is pregnant. She tells you that she is afraid to tell her
boyfriend about the pregnancy and that there are no resources available in her
neighbourhood to help her. During the interview, Monique avoids eye contact with
you and is trembling. Her clothing is stained and unkempt. She concludes the
interview by saying, “I have nowhere else to go to get help.”
Scenario 2:
You are a community worker at Youth Services Jeunesse, specifically working
with a youth group for individuals who identify as LGBTQ+. Harry, age 18,
asks to meet with you in your office. He nervously shares with you that he is a
newly diagnosed HIV-positive male. He shows you a letter from his doctor, Dr.
H. Gill, with the HIV diagnosis. The letter is in rough shape, like it has been
folded and unfolded several times, stained with something. Harry states that,
since receiving this information, he has been drinking heavily and feeling sad
and isolated. You catch whiffs of liquor on his breath as he speaks. Harry
indicates at the end of the interview that he feels his “life is over.”
Format
Create one file (saved and uploaded as a PDF) file that contains two, separate
pages (one separate page for each SOAP note).
At the top of each SOAP Note (after the title SOAP Note), indicate the following
identifying information: the date, time, and location of the meeting and who was
in attendance. You must use information included in the scenario, but you can
invent any required, missing information to complete this section.
Include each section of the SOAP Note (S · O · A · P) as indicated in the
Sample/Template on Brightspace.
Include at least three to four sentences per section.
The content of each section will be written in a narrative format: complete
sentences rather than bullet points.
You will develop your own Assessment and Plan based on the Subjective and
Objective content. They must be reasonable and logical based on the information
provided. Your Plan must include two next steps.
Type your full name, position title, and the date at the bottom of each SOAP
Note. Sign each SOAP Note above your typed name.
Maintain consistent formatting in terms of verb tense and identifiers. For
example, if you refer to the subject of the SOAP Note as “Client,” then use that
identifier throughout the document. Be cautious and consistent with pronouns.
Use the past tense throughout.
Edit your final draft for correct spelling, grammar, and punctuation.
Upload to Brightspace one file that includes both SOAP Notes.
Submission and Evaluation:
Submit your work to Brightspace by the due date indicated on the CSI.
Your work will be evaluated as per the rubric below.
Scenario 1 Scenario 2
0 .5 .75 1 0 .5 .75 1
>four required Two – three One element Identifying information is > four required Two – three One element may Identifying information is present,
elements required elements may be missing present, complete, and elements required be missing or complete, and correct (date, time, location,
missing or missing or or incomplete correct (date, time, missing or elements missing incomplete attendees)
incomplete incomplete location, attendees) incomplete or incomplete Info at bottom is present, complete, correct
Info at bottom is present, (date, name, position signature)
complete, correct (date,
name, position signature)
S > four subjective Two – three One subjective Content complete, > four subjective Two – three One subjective Content complete, subjective, avoids labels,
content errors subjective content content error subjective, avoids labels, content errors subjective content error signals inferences.
AND/OR error AND/OR signals inferences. AND/OR content error AND/OR No grammar, punctuation, verb tense,
spelling, AND/OR spelling, No grammar, punctuation, spelling, AND/OR spelling, pronoun, or spelling errors. Reported
grammar, verb spelling, grammar, grammar, verb verb tense, pronoun, or grammar, verb spelling, grammar, verb speech correct and accurate. Consistent
tense, pronoun, verb tense, tense, pronoun, spelling errors. tense, pronoun, grammar, verb tense, pronoun, reference to client.
punctuation pronoun, punctuation Reported speech correct punctuation tense, pronoun, punctuation
errors. punctuation error. errors. and accurate. Consistent errors. punctuation errors.
reference to client. error.
O > four objective Two - three One objective Content complete, > four objective Two - three One objective Content complete, objective, avoids
content errors objective content content error objective, avoids content errors objective content content error inferences.
AND/OR errors AND/OR inferences. AND/OR errors AND/OR No grammar, punctuation, verb tense,
spelling, AND/OR spelling, No grammar, punctuation, spelling, AND/OR spelling, pronoun or spelling errors. Reported
grammar, verb spelling, grammar, grammar, verb verb tense, pronoun or grammar, verb spelling, grammar, verb speech correct and accurate. Consistent
tense, pronoun, verb tense, tense, pronoun, spelling errors. Reported tense, pronoun, grammar, verb tense, pronoun, reference to client.
punctuation pronoun, punctuation speech correct and punctuation tense, pronoun, punctuation
errors. punctuation error. accurate. Consistent errors. punctuation error.
errors. reference to client. errors.
A > four Two - three One assessment Content based on S&O, > four Two - three One assessment Content based on S&O, relevant, logical,
assessment assessment content error relevant, logical, signaled assessment assessment content error signaled inferences. Consistent reference to
content errors content errors AND/OR inferences. Consistent content errors content errors AND/OR client.
AND/OR AND/OR spelling, reference to client. AND/OR AND/OR spelling, No grammar, punctuation, verb tense,
spelling, spelling, grammar, grammar, verb No grammar, punctuation, spelling, spelling, grammar, verb pronoun, or spelling errors.
grammar, verb verb tense, tense, pronoun, verb tense, pronoun, or grammar, verb grammar, verb tense, pronoun,
tense, pronoun, pronoun, punctuation spelling errors. tense, pronoun, tense, pronoun, punctuation
punctuation punctuation error. punctuation punctuation error.
errors. errors. errors. errors.
P > four plan Two - three plan One plan Content complete, based > four plan Two - three plan One plan content Content complete, based on S, O, A; logical,
content errors content errors content error on S, O, A; logical, relevant, content errors content errors error relevant, suggests two next steps.
AND/OR AND/OR spelling, AND/OR suggests two next steps. AND/OR AND/OR AND/OR No grammar, punctuation, verb tense,
spelling, grammar, verb spelling, No grammar, punctuation, spelling, spelling, spelling, pronoun, or spelling errors.
grammar, verb tense, pronoun, grammar, verb verb tense, pronoun, or grammar, verb grammar, verb grammar, verb
tense, pronoun, punctuation tense, pronoun, spelling errors. tense, pronoun, tense, pronoun, tense, pronoun,
punctuation errors. punctuation punctuation punctuation punctuation
errors. error. errors. errors. error.
/5 /5
