course materials

1. NUR 612 Hypertension SOAP Note Subjective Assessment
NUR 612 Hypertension SOAP Note Subjective AssessmentNUR 612 Hypertension SOAP
Note Subjective AssessmentSOAP is an acronym that stands for Subjective, Objective,
Assessment, and Plan. The episodic SOAP note is to be written using the attached template
below.For all the SOAP note assignments, you will write a SOAP note about one of your
patients and use the following acronym:S =Subjective data: Patient’s Chief Complaint (CC).O
=Objective data: Including client behavior, physical assessment, vital signs, and meds.A
=Assessment: Diagnosis of the patient’s condition. Include differential diagnosis.P =Plan:
Treatment, diagnostic testing, and follow upSubmission Instructions:Your SOAP note should
be clear and concise and students will lose points for improper grammar, punctuation, and
misspellingPLEASE USE BOOK AS ONE REFERENCE AND THIS IS ON AN OLDER ADULT 50
YEARS OLD AND UPORDER NOW FOR CUSTOMIZED, PLAGIARISM-FREE
PAPERSDistinguised Excellent Fair Poor Includes a direct quote from patient about
presenting problem Includes a direct quote from patient and other unrelated information
Includes information but information is NOT a direct quote Information is completely
missing 4 Points Begins with patient initials, age, race, ethnicity and gender (5
demographics) 3 Points Begins with 4 of the 5 patient demographics (patient initials, age,
race, ethnicity and gender) 2 Points Begins with 3 or less patient demographics (patient
initials, age, race, ethnicity and gender) Information is completely missing 2 Points 1.5
Points 1 Points 0 Points Includes the presenting problem and the 8 dimensions of the
problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving
factors, Timing and Severity) Includes the presenting problem and 7 of the 8 dimensions of
the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors,
Relieving factors, Timing and Severity) Includes the presenting problem and 6 of the 8
dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating
factors, Relieving factors, Timing and Severity) Information is completely missing 5 Points 3
Points 2 Points 0 Points If allergies are present, students lists only the type of allergy name
Information is completely missing 1 Points 0 Points Subjective Chief Complaint (Reason for
seeking health care) Demographics History of the Present Illness (HPI) Allergies Includes
NKA (including = Drug, If allergies are present, students lists type Drug, Environemental,
Food, Herbal, and/or Latex environemtal factor, herbal, food, latex name and or if allergies
are present (reports for each includes severity of allergy OR description of severity of
allergy AND description of allergy allergy) 2 NUR 612 Hypertension SOAP Note Subjective
AssessmentPoints Review of Systems (ROS) 1.5 Points Includes 3 or fewer assessments for

2. each body Includes 3 or fewer assessments for each body Includes a minimum of 3
assessments for each body system and assesses at least 9 system and assesses 5-8 body
systems directed to system and assesses less than 5 body systems chief complaint AND uses
the words “admits” directed to chief complaint OR student does not body systems directed
to chief complaint use the words “admits” and “denies” and “denies” AND uses the words
“admits” and “denies” 12 Points 6 Points 3 Points 0 Points Information is completely
missing 0 Points Objective Vital Signs Includes all 8 vital signs, (BP (with patient Includes 7
vital signs, (BP (with patient position), Includes 6 or less vital signs, (BP (with patient
position), HR, RR, temperature (with HR, RR, temperature (with Fahrenheit or Celsius
position), HR, RR, temperature (with Fahrenheit Fahrenheit or Celsius and route of and
route of temperature collection), weight, or Celsius and route of temperature collection),
Information is completely missing temperature collection), weight, height, BMI height, BMI
(or percentiles for pediatric weight, height, BMI (or percentiles for pediatric (or percentiles
for pediatric population) and population) and pain.) population) and pain.) pain.) 2 Points
Labs Medications Includes a list of the labs reviewed at the visit, values of lab results and
highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed. 3
Points Includes a list of all of the patient reported medications and the medical diagnosis for
the medication (including name, dose, route, frequency) 1.5 Points Includes a list of the labs
reviewed at the visit, values of lab results but does not highlight abnormal values. 1 Points 0
Points Includes a list of the labs reviewed at the visit but does not include the values of lab
results or Information is completely missing highlight abnormal values. 2 NUR 612
Hypertension SOAP Note Subjective AssessmentPoints 1 Points Includes a list of all of the
patient reported medications and the medical diagnosis for the medication (including 3 of
the 4: name, dose, medications route, frequency) Includes a list of all of the patient reported
medications (including 2 of the 4: name, dose, route, frequency) 0 Points Information is
completely missing Screenings Past Medical History 4 Points Includes an assessment of at
least 5 screening tests 2 Points Includes an assessment of at least 4 screening tests 3 Points
2 Points Includes (Major/Chronic, Trauma, Includes (Major/Chronic, Trauma,
Hospitaliztions), for each medical diagnosis, Hospitaliztions), for each medical diagnosis,
year of diagnosis and whether the diagnosis either year of diagnosis OR whether the
diagnosis is active or current is active or current 3 Points Past Surgical History Family
History Social History 0 Points Information is completely missing 1 Points 0 Points Includes
each medical diagnosis but does not include year of diagnosis or whether the diagnosis is
active or current Information is completely missing 1 Points 0 Points Includes, for each
surgical procedure, the Includes, for each surgical procedure, the year of Includes, for each
surgical procedure but not the year of procedure and the indication for the procedure OR
indication of the procedure year of procedure or indication of the procedure Information is
completely missing procedure 3 Points Includes an assessment of at least 4 family members
regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer. 3 Points
Includes all of the following: tobacco use, drug use, alcohol use, marital status, employment
status, current/previous occupation, sexual orientation, sexually active, contraceptive use,
and living situation. 3 Points Physical Examination 2 Points 1 Points Includes an assessment
of at least 3 screening tests Includes a minimum of 4 assessments for each body system and

3. assesses at least 5 body systems directed to chief complaint 12 Points 2 Points 1 Points 0
Points Includes an assessment of at least 3 family members regarding, at a minimum,
genetic disorders, diabetes, heart disease and cancer. Includes an assessment of at least 2
family members regarding, at a minimum, genetic disorders, diabetes, heart disease and
cancer. NUR 612 Hypertension SOAP Note Subjective AssessmentInformation is completely
missing 2 Points 1 Points 0 Points Includes 10 of the 11 following: tobacco use, Includes 9 or
less of the following: tobacco use, drug use, alcohol use, marital status, employment drug
use, alcohol use, marital status, employment status, current/previous occupation, sexual
status, current/previous occupation, sexual Information is completely missing orientation,
sexually active, contraceptive use, orientation, sexually active, contraceptive use, and living
situation. and living situation. 2 Points 1 Points 0 Points Includes a minimum of 3
assessments for each Includes a minimum of 2 assessments for each body system and
assesses at least 4 body systems body system and assesses at least 4 body systems
Information is completely missing directed to chief complaint directed to chief complaint 6
Points 3 Points 0 Points Assessment Diagnosis Includes a clear outline of the accurate
Includes a clear outline of the accurate diagnoses principal diagnosis AND lists the
remaining Includes an inaccurate diagnosis as the principal addressed at the visit but does
not list the Information is completely missing diagnoses addressed at the visit (in diagnosis
diagnoses in descending order of priority descending priority) 5 Points Differential
Diagnosis 3 Points 2 Points 0 Points Includes at least 3 differential diagnoses for Includes 2
differential diagnoses for the principal Includes 1 differential diagnosis for the principal
Information is completely missing the principal diagnosis diagnosis diagnosis 5 Points 3
Points Plan 2 Points 0 Points Pharmacologic treatment plan Diagnostic/Lab Testing
Education Anticipatory Guidance Follow up plan Includes a detailed pharmacologic
treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL
of the following: drug name, dose, route, frequency, duration and cost as well as education
related to pharmacologic agent. If the diagnosis is a chronic problem, student includes
instructions on currently prescribed medications as above. Includes a detailed
pharmacologic treatment plan Includes a detailed pharmacologic treatment plan for each of
the diagnoses listed under for each of the diagnoses listed under “assessment”. The plan
includes less than 4 of “assessment”. The plan includes 4 of the the following: the drug
name, dose, route, following 7: the drug name, dose, route, frequency, duration and cost as
well as education frequency, duration and cost as well as education related to
pharmacologic agent. If the diagnosis related to pharmacologic agent. If the diagnosis is is a
chronic problem, student includes a chronic problem, student includes instructions
instructions on currently prescribed medications on currently prescribed medications as
above. as above. Information is completely missing 5 NUR 612 Hypertension SOAP Note
Subjective AssessmentPoints Includes appropriate diagnostic/lab testing 100% of the time
OR acknowledges “no diagnostic testing clinically required at this time” 5 Points 3 Points 2
Points 0 Points Includes appropriate diagnostic/lab testing 50% of the time OR
acknowledges “no diagnostic testing clinically required at this time” Includes appropriate
diagnostic testing less than 50% of the time. Information is completely missing 3 Points 2
Points 0 Points Includes at least 3 strategies to promote and develop skills for managing

4. their illness and at least 3 self-management methods on how to incorporate healthy
behaviors into their lives. Includes at least 2 strategies to promote and develop skills for
managing their illness and at least 2 self-management methods on how to incorporate
healthy behaviors into their lives. Includes at least 1 strategies to promote and develop
skills for managing their illness and at least 1 self-management methods on how to
incorporate healthy behaviors into their lives. Information is completely missing 5 Points 3
Points 2 Points 0 Points Includes at least 3 primary prevention strategies (related to
age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory
guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e.
screening)NUR 612 Hypertension SOAP Note Subjective Assessment) Includes at least 2
primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and
pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies
(related to age/condition (i.e. screening)) Includes at least 1 primary prevention strategies
(related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory
guidance)) and at least 1 secondary prevention strategies (related to age/condition (i.e.
screening)) Information is completely missing 4 Points Includes recommendation for follow
up, including time frame (i.e. x # of days/weeks/months) 4 Points 2 Points Includes
recommendation for follow up, but does not include time frame (i.e. x # of
days/weeks/months) 2 Points 1 Points 0 Points Does not include follow up plan 0 Points 0
Points Moderate level of APA precision Incorrect APA style Information is completely
missing 3 Points 2 Points 1 Points 0 Points Free of grammar and spelling errors Writing
mechanics need more precision and attention to detail Writing mechanics need serious
attention 3 Points 2 Points 0 Points Writing References Grammar High level of APA
precision 0 Points SOAP Note Template Encounter date: ________________________ Patient
Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____ Reason for
Seeking Health Care: ______________________________________________
HPI:_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________
Current perception of Health: Excellent Good Fair Poor Past Medical History •
Major/Chronic Illnesses____________________________________________________ • Trauma/Injury
___________________________________________________________ • Hospitalizations
__________________________________________________________ Past Surgical
History___________________________________________________________ Medications:
__________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ Family History:
____________________________________________________________ Copyright © MVJ 2018 Social history:
Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________ Employment
Status: ______ Current/Previous occupation type: _________________ Exposure to: ___Smoke____

5. ETOH ____Recreational Drug Use: __________________ Sexual orientation: _______ Sexual Activity:
____ Contraception Use: ____________ Family Composition: Family/Mother/Father/Alone:
_____________________________ Health Maintenance Screening Tests: Mammogram, PSA,
Colonoscopy, Pap Smear, Etc _____ Exposures: Immunization HX: Review of Systems:
General: HEENT: Neck: Lungs: Cardiovascular: Breast: GI: Male/female genital: Copyright ©
MVJ 2018 GU: Neuro: Musculoskeletal: Activity & Exercise: Psychosocial: Derm: Nutrition:
Sleep/Rest: LMP: STI Hx: Physical Exam BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt.
______ BMI (percentile) _____ General: HEENT: Neck: NUR 612 Hypertension SOAP Note
Subjective AssessmentPulmonary: Cardiovascular: Breast: Copyright © MVJ 2018 GI:
Male/female genital: GU: Neuro: Musculoskeletal: Derm: Psychosocial: Misc. Significant
Data/Contributing Dx/Labs/Misc. Plan: Differential Diagnoses 1. 2. 3. Principal Diagnoses 1.
Copyright © MVJ 2018 2. Plan Diagnosis Diagnostic Testing: Pharmacological Treatment:
Education: Referrals: Follow-up: Anticipatory Guidance: Diagnosis Diagnostic Testing:
Pharmacological Treatment: Education: Referrals: Follow-up: Anticipatory Guidance:
Copyright © MVJ 2018 Signature (with appropriate credentials):
__________________________________________ Cite current evidenced based guideline(s) used to
guide care (Mandatory)_______________ DEA#: 101010101 STU Clinic LIC# 10000000 Tel:
(000) 555-1234 FAX: (000) 555-12222 Patient Name: (Initials)______________________________
Age ___________ Date: _______________ RX ______________________________________ SIG: Dispense:
___________ Refill: _________________ No Substitution Signature:
____________________________________________________________ Copyright © MVJ 2018 Copyright ©
MVJ 2018 Module 6 Assignment: SOAP Notes 3 Encounter Date: September 28, 2020 Patient
Initials: G.M. Gender: Male Age: 54 Race: White Ethnicity: Hispanic Reason for Seeking
Health Care “I feel extremely tired every day from morning to evening. I lack the energy to
perform my activities. I’ve also noted a lump on my neck.” History of Present Illness A 54-
year old white Hispanic male presented to the clinic complaining of persistent fatigue, loss
of energy, and reduced productivity at work and his normal activities. NUR 612
Hypertension SOAP Note Subjective AssessmentThe patient indicated that he works about 8
hours as a chef in a restaurant but has lost job motivation four months ago. He reports
frequent bouts of reduced mood, decreased appetite, sleepiness, and weakness in the
extremities that are transiently relieved by rest. The symptoms have worsened over the last
two months, especially after standing for long hours at work. He falls asleep immediately
when he reaches home and does not spend time chatting with his neighbors as before.
Additionally, he noted for two months, his motivation to work has reduced. He feels
unusually colder than the people around him. Further, during this period, he has noted
gradual growth Copyright © MVJ 2018 of a neck mass that is now associated with the throat
fullness and soreness. He has gained weight significantly despite reduced appetite. He says
that his vision was fine but has blurred for the last month. He fears taking large meals
because of the frequent occurrence of constipation. Allergies G.M. denies any allergies. He
does not have any allergies to environmental factors, drugs, latex, food or herbal
supplements. Current perception of Health: The patient’s health status is good. He is alert
and oriented, can explain himself coherently and has no difficulty remembering things. Past
Medical History • Major/Chronic Illnesses: G.M. denies diagnosis of chronic or significant

6. health condition. • Trauma/Injury: G.M denies major trauma or injuries. •NUR 612
Hypertension SOAP Note Subjective AssessmentHospitalizations: G.M states he’s only been
admitted once in 1996 for emergency removal of appendix. Past Surgical History
Appendectomy at age 30, in 1996. Medications Fluoxetine 60mg oral once daily, last dose,
four months ago. Copyright © MVJ 2018 Multivitamin P.O daily supplement, last dose this
morning. OTC Omeprazole PRN for gastritis, last dose 2 weeks ago. Family History Father is
alive however he has hypertension and diabetes. Mother passed away at 77, due to
Parkinson’s disease. Sister is alive however she has diabetes. Brother (1) passed away at 48,
due to a stroke. Brother (2) is alive however he has hypertension. Parental grandfather
passed away at 80, due to cancer metastasis however he was diagnosed with thyroid cancer
at 60. Parental grandmother passed away at 88, due to a stroke. He never met his maternal
grandparents. G.M denies family history of tuberculosis, kidney disease, anemia, epilepsy or
mental illness. Social history Living situation: G.M lives with his new wife and her parents in
a one story house they bought 6 months ago. They have been married for a year now.
Family composition: G.M has two children who his wife has full custody of after their
divorce 5 years ago. He states he developed mild depression following the loss of his best
friend and was Copyright © MVJ 2018 effectively managed with antidepressants and
cognitive behavioral therapy in 2019. He is no longer suffering depression therefore; he has
stopped antidepressants and behavioral therapy. Marital status: Currently married.
Occupation: G.M states he graduated from high school and went to college for one year and
did not obtain a college degree. He has been working as a chef in a restaurant for 10 years.
He was previously a bus driver for 15 years before getting into the restaurant industry.
Tobacco: G.M mentioned he is currently a smoker; he smokes two cigarettes a day. He’s
been smoking for 6 months now. ETOH/Drugs: G.M denies currently using any recreational
drugs, although he admits having used cannabis in his early adulthood. He admits to
drinking alcoholic beverages at least twice a week. Sexual orientation: G.M is heterosexual
he is currently married and is sexually active. He states he is sexually active 3 to 4 times a
week and he use’s condoms. ADLs: He admits having difficulty completing his ADLs due to
always being exhausted. NUR 612 Hypertension SOAP Note Subjective Assessment