NURS 6512 Episodic/Focused SOAP Note Template

NURS 6512 Episodic/Focused SOAP Note Template
NURS 6512 Episodic/Focused SOAP Note Template
Episodic/Focused SOAP Note Template
Assignment 1
Book: Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Format: Episodic/Focused SOAP Note format (sample attached)
Nausea and Vomiting
A 20-year-old female complains of nausea and has vomited three times over the past 48 hours. The patient also experienced a low-grade fever this morning. She states that she recently ate shellfish at a new restaurant with two friends who are suffering from similar symptoms.
Post
a description of the health history you would need to collect from the patient in the case study. Explain which physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
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Assignment 2
Book: Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins.
Video: Laureate Education, Inc. (Executive Producer). (2012). Pharmacology for the gastrointestinal system. Baltimore, MD: Author.
This media presentation outlines drug treatment options for disorders of the gastrointestinal system.
Note: The approximate length of this media piece is 2 minutes.
Format: fully detailed discussion paper
Patient HL comes into the clinic with the following symptoms: nausea, vomiting, and diarrhea. The patient has a history of drug abuse and possible Hepatitis C. HL is currently taking the following prescription drugs:
Synthroid 100 mcg daily
Nifedipine 30 mg daily
Prednisone 10 mg daily
Reflect on the patient’s symptoms, medical history, and drugs currently prescribed.
Think about a possible diagnosis for the patient. Consider whether the patient has a disorder related to the gastrointestinal and hepatobiliary system or whether the symptoms are the result of a disorder from another system or other factors such as pregnancy, drugs, or a psychological disorder.
Consider an appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed.
With these thoughts in mind:
Post
an explanation of your diagnosis for the patient including your rationale for the diagnosis. Then, describe an appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed.
Assignment 3
Book same as assignment 2
To prepare :
Review Chapter 49 of the Arcangelo and Peterson text, as well as the Krummenacher et al. and Scourfield articles in the Learning Resources.
Reflect on whether or not the prevalence of HIV cases might be attributed to increased complacency due to more advanced drug treatment options for HIV/AIDS.
Consider how health care professionals can help to change perceptions and make people more aware of the realities of the disease.
Think about strategies to educate HIV-positive patients on medication adherence, as well as safe practices to reduce the risk of infecting others.
With these thoughts in mind:
By Day 3
Post
an explanation of whether or not you think the prevalence of HIV cases might be attributed to increased complacency due to more advanced drug treatment options. Then, explain how health care professionals can help to change perceptions and increase awareness of the realities of the disease. Finally, describe strategies to educate HIV-positive patients on medication adherence, as well as safe practices to reduce the risk of infecting others.
Episodic/Focused SOAP Note Template SAMPLE
Patient Information:
Initials, Age, Sex, Race
S.
CC
(chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance, “headache”, NOT “bad headache for 3 days”.
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. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was a “headache”, the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications
: include dosage, frequency, length of time used, and reason for use; also include OTC or homeopathic products.
Allergies:
include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMH
: include immunization status (note date of
last tetanus
for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx
: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), and any other pertinent data. Always add some health promo questions here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx
: illnesses with possible genetic predisposition, contagious or chronic illnesses. The reason for the death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS
: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam
: 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.
Do not use “WNL” or “normal.” You must describe what you see.
Always document in head-to-toe format i.e. General: Head: EENT: etc.
Diagnostic results
: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidence and guidelines)
A
.
Differential Diagnoses
(list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Episodic/Focused SOAP Note Template References
You are required to include at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differential diagnoses. Be sure to use correct APA 6th edition formatting.
Example
Focused SOAP Note for a patient with chest pain
S.

CC: “Chest pain”
HPI: The patient is a 65-year-old AA male who developed sudden onset of chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms.
PMH: Positive history of GERD and hypertension is controlled
FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature cardiovascular disease in first-degree relatives.
SH: Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years
ROS
General
–Negative for fevers, chills, fatigue
Cardiovascular
–Negative for orthopnea, PND, positive for intermittent lower extremity edema
Gastrointestinal
–Positive for nausea without vomiting; negative for diarrhea, abdominal pain
Pulmonary
–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis
O.
VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”
General
–Pt appears diaphoretic and anxious
Cardiovascular
–PMI is in the 5th inter-costal space at the midclavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the
second right intercostal space which radiates to the neck.
A third heard sound is heard at the apex. No fourth heart sound or rub is heard. No cyanosis, or clubbing, is noted, and positive for bilateral 2+ LE edema is noted.
Gastrointestinal
–The abdomen is symmetrical without distention; bowel
sounds are normal in quality and intensity in all areas; a
bruit is heard in the right para-umbilical area. No masses or
splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.
Pulmonary
— Lungs are clear to auscultation and percussion bilaterally
Diagnostic results: EKG, CXR, CK-MB (support with evidence and guidelines)
A.
Differential Diagnosis:
1) Myocardial Infarction (provide supportive documentation with evidence-based guidelines).
2) Angina (provide supportive documentation with evidence-based guidelines).
3) Costochondritis (provide supportive documentation with evidence-based guidelines).
Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
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