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Comprehensive SOAP Template

Comprehensive SOAP TemplateComprehensive SOAP TemplateWeek 4 Lab Assignment: Differential Diagnosis for Skin ConditionsPatient Initials: _______ Age: _______ Gender: _______ Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.O = onset of symptom (acute/gradual)L= locationD= duration (recent/chronic)C= characterA= associated symptoms/aggravating factorsR= relieving factorsT= treatments previously tried – response? Why discontinued?S= severity SUBJECTIVE DATA: Include what the patient tells you, but organize the information. Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.Comprehensive SOAP TemplateHistory of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:1. Location2. Quality3. Quantity or severity4. Timing, including onset, duration, and frequency5. Setting in which it occurs6. Factors that have aggravated or relieved the symptom7. Associated manifestationsORDER A PLAGIARISM-FREE PAPER HEREMedications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency. Allergies: Include specific reactions to medications, foods, insects, and environmental factors.Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors. Past Surgical History (PSH): Include dates, indications, and types of operations. Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function. Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits. Immunization History: Include last Tdp, Flu, pneumonia, etc.Comprehensive SOAP TemplateSignificant Family History: Include history of parents, Grandparents, siblings, and children. Lifestyle: Include cultural factors, economic factors, safety, and support systems. Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text. General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.HEENT:Neck:Breasts:Respiratory:Cardiovascular/Peripheral Vascular:Gastrointestinal:Genitourinary:Musculoskeletal:Psychiatric:Neurological:Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.Hematologic:Endocrine:Allergic/Immunologic: OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see. Physical Exam:Vital signs: Include vital signs, ht, wt, and BMI.General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.HEENT:Comprehensive SOAP Template Neck:Chest/Lungs: Always include this in your PE.Heart/Peripheral Vascular: Always include the heart in your PE.Abdomen:Genital/Rectal:Musculoskeletal:Neurological:Skin: ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan. PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses. Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines. Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines. Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines. REFLECTION: Reflect on your clinical experience and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence?Comprehensive SOAP Exemplar Purpose: To demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.Comprehensive SOAP TemplatePatient Initials: _______ Age: _______ Gender: _______ SUBJECTIVE DATA: Chief Complaint (CC): Coughing up phlegm and fever History of Present Illness (HPI): Sara Jones is a 65 year old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last three days. She reported that the “cold feels like it is descending into her chest”. The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4, last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10. Medications:1.) Lisinopril 10mg daily2.) Combivent 2 puffs every 6 hours as needed3.) Serovent daily4.) Salmeterol daily5.) Over the counter Ibuprofen 200mg -2 PO as needed6.) Over the counter Benefiber7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms Allergies:Sulfa drugs – rash Past Medical History (PMH):1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and an hand held nebulizer treatments.2.) Hypertension – well controlled3.) Gastroesophageal reflux (GERD) – quiet on no medication4.) Osteopenia5.) Allergic rhinitisComprehensive SOAP TemplatePast Surgical History (PSH):1.) Cholecystectomy 19942.) Total abdominal hysterectomy (TAH) 1998 Sexual/Reproductive History:HeterosexualG1P1A0Non-menstrating – TAH 1998 Personal/Social History:She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use. Immunization History:Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time. Significant Family History:Two brothers – one with diabetes, dx at age 65 and the other with prostate CA, dx at age 62. She has 1 daughter, in her 50’s, healthy, living in nearby neighborhood. Lifestyle:She is a retired; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. She college graduate, owns her home and receives a pension of $50,000 annually – financially stable. She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center and she attends regularly. She enjoys bingo. She has a good support system composed of family and friends.Comprehensive SOAP TemplateReview of Systems: General: + fatigue since the illness started; + fever, no chills or night sweats; no recent weight gains of losses of significance. HEENT: no changes in vision or hearing; she does wear glasses and her last eye exam was 1 ½ years ago. She reported no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. She does have bilateral small cataracts that are being followed by her ophthalmologist. She has had no recent ear infections, tinnitus, or discharge from the ears. She reported her sense of smell is intact. She has not had any episodes of epistaxis. She does not have a history of nasal polyps or recent sinus infection. She has history of allergic rhinitis that is seasonal. Her last dental exam was 3/2014. She denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. She has had no difficulty chewing or swallowing.Neck: no pain, injury, or history of disc disease or compression. Her last Bone Mineral density (BMD) test was 2013 and showed mild osteopenia, she said. Breasts: No reports of breast changes. No history of lesions, masses or rashes. No history of abnormal mammograms.Comprehensive SOAP TemplateRespiratory: + cough and sputum production (see HPI); denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; she has history of COPD and community acquired pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago. CV: no chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. Date of last ECG/cardiac work up is unknown by patient. GI: No nausea or vomiting, reflux controlled, No abd pain, no changes in bowel/bladder pattern. She uses fiber as a daily laxative to prevent constipation. GU: no change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She has had a total abd hysterectomy. No history of STD’s or HPV. She has not been sexually active since the death of her husband. MS: she has no arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. No history of trauma or fractures. Psych: no history of anxiety or depression. No sleep disturbance, delusions or mental health history. She denied suicidal/homicidal history. Neuro: no syncopal episodes or dizziness, no paresthesia, head aches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history. Integument/Heme/Lymph: no rashes, itching, or bruising. She uses lotion to prevent dry skin. She has no history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties or history of transfusions. Endocrine: no endocrine symptoms or hormone therapies. Allergic/Immunologic: this has hx of allergic rhinitis, but no known immune deficiencies. Her last HIV test was 10 years ago.  OBJECTIVE DATA Physical Exam:Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 Orally; RR 16; non-labored; Wt: 115 lbs; Ht: 5’2; BMI 21General: A&O x3, NAD, appears mildly uncomfortableHEENT: PERRLA, EOMI, oronasopharynx is clearNeck: Carotids no bruit, jvd or tmegallyChest/Lungs: CTA AP&LHeart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radialABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no reboundGenital/Rectal: external genitalia intact, no cervical motion tenderness, no adnexal masses.Musculoskeletal: symmetric muscle development – some age related atrophy; muscle strengths 5/5 all groups.Neuro: CN II – XII grossly intact, DTR’s intactSkin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodesComprehensive SOAP TemplateASSESSMENT: Lab Tests and Results:CBC – WBC 15,000 with + left shiftSAO2 – 98% Diagnostics:Lab:Radiology:CXR – cardiomegaly with air trapping and increased AP diameterECGNormal sinus rhythm Differential Diagnosis (DDx):1.) Acute Bronchitis2.) Pulmonary Embolis3.) Lung Cancer Diagnoses/Client Problems: 1.) COPD2.) HTN, controlled3.) Tobacco abuse – 40 pack year history4.) Allergy to sulfa drugs – rash5.) GERD – quiet on no current medication PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]Comprehensive SOAP Template

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