How to Meet Every Rubric Section
100 points. 22 rubric criteria. One clinical presentation. This guide breaks down what each section of the PID SOAP note needs to contain, what the grader is checking for, and exactly which clinical details to build into your patient scenario — from OLD CARTS through the prescription pad to the reference list.
The rubric for this SOAP note is detailed and unforgiving. Miss one component in the HPI and you drop a full point. Leave out the evidence level for two body systems in the ROS and you can lose up to 12 points in that section alone. PID is a well-defined clinical presentation with a clear CDC-backed treatment protocol — so the clinical content isn’t the hard part. The hard part is making sure every rubric box is ticked, in every section, in the right format. This guide goes section by section.
What This Guide Covers
Rubric Overview and Point Distribution
Before you write a single word, map the points. This rubric is 100 points across 22 criteria. The high-stakes sections are ROS (15 pts), Physical Exam (15 pts), HPI (5 pts), Diagnosis (5 pts), Differential Diagnosis (5 pts), and Pharmacologic Treatment Plan (5 pts). Those six sections alone account for 50% of the total grade. Get those right first.
| Rubric Section | Max Points | Key Requirement for Full Marks |
|---|---|---|
| Demographics | 1 | All 5: initials, age, race, ethnicity, gender |
| Chief Complaint | 4 | Direct quote from patient — in quotation marks |
| HPI | 5 | All 8 OLD CARTS dimensions + presenting problem |
| Allergies | 2 | NKA (all 5 types listed) OR allergy name + severity + description |
| Review of Systems | 15 | ≥9 body systems, ≥3 assessments each, uses “admits” and “denies” |
| Vital Signs | 2 | All 8: BP (position), HR, RR, Temp (F or C + route), Wt, Ht, BMI, Pain |
| Labs | 2 | List + values + abnormal values highlighted OR “no labs reviewed” |
| Medications | 4 | All meds: name, dose, route, frequency + diagnosis |
| Past Medical History | 3 | Major/chronic, trauma, hospitalizations + year + active/resolved status |
| Past Surgical History | 3 | Each procedure + year + indication |
| Family History | 3 | ≥4 family members, includes genetic disorders, DM, heart disease, cancer |
| Social History | 3 | All 11: tobacco, drugs, alcohol, marital, employment, occupation, sexual orientation, sexually active, contraception, living situation (+ 1 more) |
| Health Maintenance / Screenings | 3 | Immunization status + ≥5 age-appropriate screening tests |
| Physical Examination | 15 | ≥5 body systems, ≥4 assessments per system, directed to chief complaint |
| Diagnosis | 5 | Principal diagnosis clearly stated + remaining diagnoses in descending priority |
| Differential Diagnosis | 5 | ≥3 differentials for the principal diagnosis |
| ICD-10 Coding | 3 | Correct codes for all diagnoses addressed at the visit |
| Pharmacologic Treatment Plan | 5 | All 7 elements: drug, dose, route, frequency, duration, cost, education — for each diagnosis |
| Diagnostic / Lab Testing | 3 | Appropriate testing ordered OR “no testing clinically required at this time” |
| Education | 3 | ≥3 illness management strategies + ≥3 healthy behaviour self-management methods |
| Anticipatory Guidance | 3 | ≥3 primary prevention strategies + ≥2 secondary prevention strategies |
| Follow-Up Plan | 2 | Recommendation + specific time frame (days/weeks/months) |
| Prescription | 3 | All fields: patient info, date, drug, dose, route, frequency, quantity, refills, provider signature + credentials |
| Writing Mechanics / APA / Citations | 3 | APA 7th, error-free, all claims cited, DOI-linked references 2022–2026 |
SUBJECTIVE Section — What Every S Criterion Needs
The subjective section is where most points are quietly lost. Not because the clinical content is wrong — but because a required field is incomplete. Demographics missing one element. Allergies listed without severity. Medications without the route. Check each criterion against the rubric before moving on.
All Five Elements, Right at the Top
The rubric requires: patient initials, age, race, ethnicity, and gender. That’s five distinct items. “J.M., a 24-year-old Hispanic White female” — that’s initials, age, ethnicity (Hispanic), race (White), and gender. All five. The rubric awards full marks only when all five are present. A common error: listing race and ethnicity as a single item. They’re separate fields.
For PID: The typical presentation is a sexually active woman of reproductive age. Your demographic profile should be consistent with the epidemiology — most commonly ages 15–44, with higher incidence in younger, sexually active populations.A Direct Quote. In Quotation Marks. Nothing Else.
This is a 4-point criterion with one rule: the chief complaint must be a direct quote from the patient — in quotation marks, in the patient’s words, not clinical language. “I’ve been having really bad pain in my lower belly for the past three days, and it hurts worse when I have sex” scores full marks. “Patient presents with pelvic pain and dyspareunia” does not — that’s clinical paraphrase, not a direct quote. The rubric explicitly deducts for this.
Common PID presentations in direct quote format: Lower abdominal or pelvic pain, abnormal vaginal discharge, pain with intercourse, fever, and irregular bleeding. Build the quote around what a real patient would say, not what a textbook says.NKA Needs All Five Types Listed. Present Allergies Need Severity AND Description.
If the patient has no known allergies, write “NKA” and list all five allergy categories: drug, environmental, food, herbal, and latex — all with NKA notation for each. If allergies are present, the full-marks requirement is allergy name + severity (mild/moderate/severe) + description of the reaction (hives, anaphylaxis, GI upset, etc.). Listing just “Penicillin allergy” without severity and reaction description puts you in the partial-credit range.
HPI — Building All 8 OLD CARTS Dimensions
The HPI is 5 points and requires all 8 dimensions of OLD CARTS plus the presenting problem. Miss one and you drop into the 3-point range. Miss two and it’s 2 points. Map your scenario carefully before writing — it’s easier to build all 8 in when you’re planning than to retrofit them after.
OLD CARTS — All 8 Dimensions for PID
- O — Onset: When did the pelvic pain start? Sudden vs. gradual. Days to weeks. Relate to recent sexual activity, new partner, or recent menstruation if relevant.
- L — Location: Lower abdominal/pelvic, bilateral vs. unilateral. Does it radiate? PID classically presents with bilateral lower quadrant tenderness.
- D — Duration: How long has it been present? Acute PID typically presents within days to 2 weeks of onset.
- C — Character: Dull, crampy, aching, sharp. Constant vs. intermittent. Patients often describe a deep, persistent pelvic ache.
- A — Aggravating factors: Sexual intercourse (dyspareunia is a hallmark), movement, urination, or bowel movements.
- R — Relieving factors: OTC analgesics (partial relief), rest, heat. Note what doesn’t help — guides treatment urgency.
- T — Timing: Constant or intermittent? Any relationship to the menstrual cycle? Onset within two weeks of menstruation is clinically significant for PID.
- S — Severity: Pain scale 0–10. Include the number — not just “moderate” or “severe.”
Additional Clinical Details to Include in the HPI
Beyond OLD CARTS, a strong PID HPI captures the full clinical picture. Include:
- Associated symptoms: abnormal vaginal discharge (colour, odour, quantity), fever/chills, nausea/vomiting, irregular vaginal bleeding, urinary symptoms
- Sexual history relevant to onset: new or multiple partners, recent unprotected intercourse, STI history
- Recent procedures: IUD insertion within the last 3 weeks increases PID risk significantly
- Last menstrual period (LMP) — required separately in the ROS but relevant context in the HPI
- What the patient has tried so far: OTC medications, any prior treatment
ROS — 9+ Body Systems, “Admits” and “Denies”
The ROS is worth 15 points. This is the highest-stakes section outside the physical exam. The rubric requires at least 9 body systems, at least 3 assessments per system, and the specific words “admits” and “denies” throughout. All three conditions must be met for full marks. Miss one and you lose up to 7 points immediately.
The rubric specifically checks for these two words. Using “reports,” “states,” “says,” or “positive/negative for” instead will cost you marks — even if your content is clinically accurate. Use “Patient admits to [symptom]” and “Patient denies [symptom]” consistently throughout the ROS. This is non-negotiable for the 15-point score.
Constitution
Fever, chills, fatigue, malaise, unintentional weight change, night sweats. PID: patient will likely admit to fever and fatigue; denies weight change.
Head, Eyes, Ears, Nose, Throat
Headache, visual changes, ear pain, nasal congestion, sore throat, oral lesions. Typically negative for PID; must still be included as directed system.
Lymphadenopathy, Pain, Stiffness
Lymph node swelling, neck stiffness, pain with movement. Include for completeness; PID patients usually deny neck findings.
Cardiovascular
Chest pain, palpitations, shortness of breath on exertion, leg swelling, syncope. Important baseline; PID-associated sepsis could affect cardiovascular status.
Gastrointestinal
Nausea, vomiting, diarrhoea, constipation, abdominal pain, bloating. PID patients often admit to nausea and lower abdominal pain; relevant for differential (appendicitis, ectopic pregnancy).
Genitourinary & Female Genital
Vaginal discharge (colour, odour, amount), dysuria, urinary frequency, dyspareunia, abnormal uterine bleeding, LMP, STI history. This is the most critical ROS section for PID — needs full detail.
MSK
Joint pain, muscle aches, back pain, limited range of motion. Include pelvic girdle pain; patient may admit to lower back pain associated with PID.
Neurological & Psychosocial
Headache, dizziness, anxiety, mood changes, depression screening. Psychosocial section can address stress, anxiety related to STI diagnosis concerns.
Skin & Respiratory
Skin rash (relevant for disseminated gonorrhoea rule-out), lesions; cough, shortness of breath, wheezing for respiratory. Include both for system count.
The template specifically lists LMP (last menstrual period) and STI History as separate ROS items. Both are clinically essential for PID. The LMP helps rule out ectopic pregnancy (a critical differential). STI history documents prior chlamydia or gonorrhoea infections — a major risk factor for PID recurrence. Each needs at least 3 sub-assessments to meet the rubric standard for that system.
OBJECTIVE Section — Vitals, Labs, Physical Exam
All 8 — Including Position for BP and Route for Temp
The rubric awards full marks only when all 8 vital signs are present: BP with patient position (sitting, standing, or supine), HR, RR, temperature (with Fahrenheit or Celsius AND route — oral, tympanic, axillary, rectal), weight, height, BMI, and pain scale (0–10). For a PID patient, expect a low-grade to moderate fever — build that into the temperature. Pain score should be consistent with the chief complaint intensity described in the HPI.
Common PID vital sign presentation: BP sitting 118/74 mmHg, HR 96 bpm, RR 16 breaths/min, Temp 38.2°C (100.8°F) oral, Wt 62 kg, Ht 163 cm, BMI 23.3, Pain 7/10.List + Values + Flag Abnormals
For a PID presentation, relevant labs include a urine pregnancy test (rule out ectopic), urinalysis (rule out UTI), CBC (elevated WBC expected), CRP or ESR (inflammatory markers), cervical swabs for GC/chlamydia (NAAT), and wet prep/vaginal pH. List each test, the result value, and highlight any abnormal findings — elevated WBC, positive NAAT, elevated CRP. If labs are pending or were not reviewed at this visit, state that explicitly. Do not leave this section blank.
Physical Exam — 15 Points, 5 Systems, 4 Assessments Each
The PE is worth 15 points and requires at least 5 body systems with at least 4 assessments per system. That’s a minimum of 20 documented findings. They must be directed to the chief complaint — random, irrelevant findings won’t score. For PID, the exam must include the pelvic/genital exam.
5 Systems to Include for PID (4 Findings Each)
- General: Appearance, level of distress, orientation, skin colour/hydration, mood/affect
- Abdomen/GI: Inspection, auscultation (bowel sounds), percussion, palpation (tenderness location, guarding, rigidity, rebound)
- Female Genital/GU: External genitalia inspection, vaginal speculum exam (discharge characteristics, cervical appearance), cervical motion tenderness (CMT), uterine tenderness, adnexal tenderness — these are the clinical hallmarks of PID
- Cardiovascular: Heart rate and rhythm, heart sounds (S1/S2), peripheral pulses, capillary refill
- Musculoskeletal: Gait, posture, range of motion, lower extremity assessment, pelvic girdle tenderness
The Three Clinical Criteria for PID Diagnosis
The CDC 2021 STI Treatment Guidelines state that PID diagnosis is based on minimum criteria. Your physical exam must document all three of these findings to support the diagnosis clinically:
- Cervical motion tenderness (CMT) — elicited on bimanual exam; document as positive or negative
- Uterine tenderness — on bimanual palpation; document as present/absent with quality
- Adnexal tenderness — bilateral or unilateral; document findings for both adnexa
At least one of these must be present for PID diagnosis. Building all three positive into your PID scenario strengthens the clinical picture and supports your diagnosis section.
ASSESSMENT — Diagnosis, Differentials, and ICD-10
Principal Diagnosis First, Then All Others in Descending Priority
The principal diagnosis for this SOAP note is Pelvic Inflammatory Disease. State it clearly and specifically. Then list any additional diagnoses addressed at the visit in descending order of priority — this might include cervicitis, STI co-infection (chlamydia, gonorrhoea), or secondary diagnoses like a urinary tract infection or anaemia. “Descending priority” means clinical urgency, not alphabetical. Acute PID sits at the top. Chronic conditions addressed at the same visit (e.g., ongoing contraceptive management) come after.
At Least 3 Differentials for the Principal Diagnosis
Full marks require at least 3 differentials. For PID presenting with lower abdominal pain, these are your strongest differentials. Each should be named and briefly explained — why it was considered and what ruled it out or made it less likely.
Strong PID differentials: 1. Ectopic pregnancy — ruled out by negative urine pregnancy test and confirmed last menstrual period 2. Appendicitis — typically presents with right lower quadrant localised pain, fever, and elevated WBC; pain is peritoneal, not cervical 3. Ovarian cyst/torsion — sudden, severe, unilateral pain; often lacks the cervical/vaginal findings of PID 4. Endometriosis — cyclic pain pattern, typically not associated with fever or vaginal discharge 5. Urinary tract infection — dysuria-focused, confirmed/excluded by urinalysisCorrect Codes for Every Diagnosis Addressed
All diagnoses listed in the Assessment section need a corresponding ICD-10 code. Accuracy is what the rubric checks — getting all codes correct earns 3 points; most correct earns 2. Common PID-related ICD-10 codes to consider:
Key ICD-10 codes for PID:N73.0 — Acute parametritis and pelvic cellulitis (primary PID code)
N70.01 — Acute salpingitis
N70.11 — Acute salpingo-oophoritis
A56.11 — Chlamydial female pelvic inflammatory disease
A54.24 — Gonococcal female pelvic inflammatory disease (if GC confirmed)
N72 — Inflammatory disease of cervix uteri (if cervicitis also addressed)
Use the most specific code the clinical documentation supports — not a general category code when a specific one applies.
PLAN Section — Pharmacologic, Labs, Education, Guidance
All 7 Elements for Every Drug, for Every Diagnosis
This is a 5-point section where partial answers cost marks proportionally. The rubric requires all 7 elements for each medication: drug name, dose, route, frequency, duration, cost, and patient education. Do that for every drug in the plan — and for chronic diagnoses, also document instructions for existing medications using the same 7-element format.
Full-marks approach for each drug entry:Drug name (generic + brand) → Dose (specific mg) → Route (oral, IM, IV) → Frequency (once daily, BID, single dose) → Duration (14 days, single dose) → Cost (approximate out-of-pocket or GoodRx price, generic vs. brand) → Patient education (what to expect, side effects, when to return).
The CDC STI Treatment Guidelines (2021, updated 2023) are the authoritative clinical reference for PID pharmacologic treatment. Outpatient regimen: Ceftriaxone 500 mg IM × 1 dose, plus doxycycline 100 mg oral BID × 14 days, plus metronidazole 500 mg oral BID × 14 days. Your pharmacologic plan must document all three agents, each with all 7 rubric elements. This CDC source also qualifies as one of your three required references — it has a citable URL and current publication date within the 2022–2026 window.
| Drug | Role in PID Tx | 7 Elements Needed |
|---|---|---|
| Ceftriaxone (Rocephin) | Covers gram-negative organisms including N. gonorrhoeae | Name, 500 mg, IM, single dose, 1 day, cost (clinic-administered), education on injection site |
| Doxycycline (Vibramycin) | Covers C. trachomatis and other anaerobes | Name, 100 mg, oral, twice daily, 14 days, cost (~$10–20 generic), education on photosensitivity, take with food, avoid calcium |
| Metronidazole (Flagyl) | Anaerobic coverage; treats BV co-infection | Name, 500 mg, oral, twice daily, 14 days, cost (~$10–15 generic), education on alcohol avoidance, metallic taste, take with food |
Three Illness Management Strategies + Three Healthy Behaviour Methods
Two separate sets of three. The illness management strategies are disease-specific: what to do to manage PID, recognise complications, and support recovery. The healthy behaviour methods are broader self-management: lifestyle habits that promote health beyond the acute episode. These are different things — don’t blend them into one list.
Illness management strategies for PID:(1) Complete the full 14-day antibiotic course even if symptoms improve — stopping early risks treatment failure and recurrence
(2) Abstain from sexual intercourse until the full course of antibiotics is completed and symptoms resolve completely
(3) Notify all sexual partners within the past 60 days so they can be tested and treated — partner notification prevents reinfection
Healthy behaviour self-management methods:
(1) Consistent condom use reduces STI acquisition risk and prevents future PID episodes
(2) Annual STI screening for sexually active women under 25 (per USPSTF recommendation)
(3) Limiting number of sexual partners reduces STI exposure risk
Three Primary Prevention Strategies + Two Secondary Prevention Strategies
Primary prevention means stopping the disease before it occurs — immunizations, behaviour modification, protective measures. Secondary prevention means early detection of existing disease — screening. These are clinically distinct and the rubric counts them separately.
Primary prevention (×3):(1) HPV vaccination if not previously completed (ACIP recommends through age 26 routinely; shared decision-making through age 45)
(2) Hepatitis B vaccination series if not immune (sexual transmission risk)
(3) Consistent barrier contraceptive use and sexual partner reduction as behavioural primary prevention against STIs
Secondary prevention (×2):
(1) Annual chlamydia and gonorrhoea NAAT screening for all sexually active women under 25 (USPSTF Grade B recommendation)
(2) HIV screening at least once for all adults 15–65; more frequent for high-risk individuals (USPSTF Grade A)
Diagnostic/Lab Testing — 3 Points
Order appropriate testing for PID at this visit and document each test with its clinical rationale. Required labs for PID workup:
- Urine pregnancy test (hCG) — rule out ectopic pregnancy before treating
- NAAT for Chlamydia trachomatis and Neisseria gonorrhoeae (cervical or vaginal swab)
- Wet prep and vaginal pH — assess for BV and Trichomonas co-infection
- CBC with differential — evaluate WBC for infection severity
- CRP or ESR — inflammatory marker baseline; guides treatment response monitoring
- Urinalysis with culture — rule out UTI as differential
Follow-Up Plan — 2 Points
The rubric requires a specific time frame — not just “follow up as needed.” Two components must be present:
- Recommendation: return to clinic for repeat evaluation
- Time frame: 72 hours for outpatient PID (CDC guideline — to assess treatment response and determine if inpatient admission is needed)
- Additional: if no improvement at 72 hours, reassess for inpatient IV antibiotic therapy
- Retest for GC/chlamydia in 3 months after treatment completion
Prescription — All 9 Required Components
The prescription section is 3 points and has a fixed checklist. Missing 1–2 components drops you to 2 points. Missing 3 or more puts you at 1 point. The template is provided — fill every field.
Prescription Checklist — PID
References — 3 Sources, 2022–2026, with DOI
Three references, all published between 2022 and 2026, all with DOI numbers. That’s the requirement. The CDC STI Treatment Guidelines (2021, updated 2023) qualifies as one. The other two should come from peer-reviewed nursing or clinical journals — search CINAHL or PubMed for recent PID management articles.
Where to Find PID References (2022–2026)
- PubMed: Search “pelvic inflammatory disease treatment 2023” or “PID management nursing” — filter for last 3 years
- CINAHL: Best for nursing-specific articles on STI management and women’s health
- CDC STI Treatment Guidelines 2021 (updated 2023): Citable as a government guideline with URL as DOI substitute
- ACOG (American College of Obstetricians and Gynecologists): PID practice bulletins are within date range
- Sexually Transmitted Infections journal (BMJ): High-quality peer-reviewed source with current PID evidence
APA 7th Reference Format
Every reference needs a DOI. Format for a journal article:
Author, A. A., & Author, B. B. (Year). Title of article. Journal Name, Volume(Issue), pages. https://doi.org/xxxxx
For the CDC guideline: Centers for Disease Control and Prevention. (2023). Sexually transmitted infections treatment guidelines, 2021: Pelvic inflammatory disease. https://www.cdc.gov/std/treatment-guidelines/pid.htm
The pharmacologic plan, diagnostic testing recommendations, education content, and anticipatory guidance should all cite the evidence they’re based on. “Per CDC STI Treatment Guidelines (2023)” before the treatment regimen. USPSTF citation for screening recommendations. Don’t write the plan from memory and cite only the reference list — the grader is checking for citations at the point of claim, not just a reference page that exists.
Mistakes That Cost the Most Points
Chief Complaint Without Quotation Marks
Writing “Patient presents with pelvic pain and vaginal discharge” as the CC. That’s a clinical summary, not a direct patient quote. It scores in the 2-point range, not 4.
Build a Realistic Patient Quote
“I’ve had really bad pain in my lower belly for about four days and it hurts a lot when I have sex. I also noticed a weird-smelling discharge that’s been getting worse.” Quotation marks. Patient’s words. Direct quote.
ROS Without “Admits” and “Denies”
Using “positive for,” “reports,” or “states” throughout the ROS. The rubric checks specifically for these two words — not synonyms. Students who use substitute language lose the full 15-point ROS score.
Use the Exact Words — Every System
“Patient admits to lower abdominal pain, fever, and increased vaginal discharge. Patient denies nausea, vomiting, and urinary symptoms.” Repeat this structure for all 9+ systems.
Pharmacologic Plan Missing Cost
Drug name, dose, route, frequency, and duration — but no cost. That’s only 5 of the required 7 elements. Cost is an explicit rubric field and missing it pushes the plan below the full-marks threshold.
Include Actual Cost Estimates
Use GoodRx or similar to document approximate cash prices. “Generic doxycycline 100 mg, 28 tablets: approximately $10–18 without insurance (GoodRx, 2024).” One sentence per drug. That’s the cost element done.
Prescription Missing Refills or Quantity
Filling out the drug name and SIG but leaving Dispense and Refill blank on the template. Both fields are explicitly listed in the rubric’s prescription criterion. Blank = missing component = 2 points instead of 3.
Fill Every Prescription Field
Dispense: 28 tablets (14-day BID course). Refill: 0. No Substitution: checked. Both signature lines completed with credentials. Date matches the visit date in demographics.
Frequently Asked Questions
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SOAP Note Writing Service Get StartedThe Rubric Is Your Outline
Every section of this SOAP note maps directly to a rubric criterion with a point value attached. That’s actually a gift. You’re not guessing what the grader wants — it’s written out. The students who lose marks on a note like this aren’t losing them because they don’t know PID clinically. They’re losing them because they missed a demographic field, forgot to include BP position in the vitals, or wrote the chief complaint in clinical language instead of a patient quote.
Read the rubric before you write. Then read it again after. Print it out and check each box. The 72-hour follow-up. The cost on every drug. The “admits” and “denies” in every ROS paragraph. The credentials on both signature lines. Small things. But 100-point rubrics are won and lost on small things.