Episodic/Focused SOAP Note Template 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 “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). PMHx: 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), any other pertinent data. Always add some health promo question 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. Reason for 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:  Denies weight loss, fever, chills, weakness or fatigue. HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat. SKIN:  Denies rash or itching. CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIR.

1. Episodic/Focused SOAP Note Template
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 “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,

2. anaphylaxis, etc. This will help determine a true reaction vs
intolerance).
PMHx: 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), any
other pertinent data. Always add some health promo question
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. Reason for 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: Denies weight loss, fever, chills, weakness or
fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision
or yellow sclerae. Ears, Nose, Throat: Denies hearing loss,
sneezing, congestion, runny nose or sore throat.
SKIN: Denies rash or itching.

3. CARDIOVASCULAR: Denies chest pain, chest pressure or
chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or
diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last
menstrual period, MM/DD/YYYY.
NEUROLOGICAL: Denies headache, dizziness, syncope,
paralysis, ataxia, numbness or tingling in the extremities. No
change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain
or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of
splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat
intolerance. No polyuria or polydipsia.
ALLERGIES: Denies 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 evidenced and guidelines)
A.
Differential Diagnoses (list a minimum of 3 differential

4. diagnoses).Your primary or presumptive diagnosis should be at
the top of the list. For each diagnosis, provide supportive
documentation with evidence based guidelines.
P.
This section is not required for the assignments in this course
(NURS 6512) but will be required for future courses.
References
You are required to include at least three evidence based peer-
reviewed journal articles or evidenced based guidelines which
relates to this case to support your diagnostics and differentials
diagnoses. Be sure to use correct APA 7th edition formatting.
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ATTACHED ARE FOUR ESSAYS THAT NEED TO BE 500 TO
1000 WORDS EACH.
ESSAY ONE- I HAVE ATTACHED THE SCHOOL WEBSITE
AND COPY THEIR VALUES
ESSAY TWO- I HAVE PUT NOTES UNDER THE QUESTION
OF TOPICS TO INCLUDE IN THE ESSAY
ESSAY THREE- DISCUSS ADVOCACY IN DETAIL
ESSAY FOUR- PLEASE GIVE A GOOD INTRO PARAGRAPH.
THE SITUATION CAN EITHER BE MADE-UP OR LEAVE A
NOTE SO I CAN INSERT MORE DETAILS
DUE 10/27/2022 BY 10PM CENTRAL TIME

5. 1. Explain and provide examples of how you model Methodist
College’s values.
a.
Methodist College | Mission, Vision and Values the
school link
Mission
Methodist College is committed to providing quality
educational programs that promote holistic development, civic
engagement, and community service to a diverse student
population of future healthcare and human services
professionals.
Vision
Methodist College will be the premier college of choice for
excellence in Health Science and Human Service education
within the Midwest.
Values
Human Dignity: Unconditional respect for the inherent worth,
uniqueness, and autonomy of individuals.
Integrity: Displaying strong moral character and acting in
accordance with accepted standards of behavior and an
appropriate code of ethics.
Inquiry: An active process of exploration and investigation that
leads to understanding and construction of knowledge

6. throughout one's life.
Social Justice: Acting in accordance with fair treatment
regardless of gender, economic status, race, religion, ethnicity,
age, citizenship, disability, or sexual orientation.
Institutional Goals
· Create and support a positive, student-centered learning
environment.
· Provide quality instruction and programs.
· Create quality student support services and programs.
· Recruit and retain a diverse, qualified workforce.
· Promote fiscal responsibility and accountability.
· Provide adequate resources to support institutional mission.
· Recruit and retain a qualified, diverse student body.
· Develop collaborative relationships for the benefit of the
community.
MC's Diversity Statement:
Methodist College is an institution that embraces a diverse
community committed to the equity of all dimensions and
demographics. We strive to produce an environment of safety,
comfort, respect, and civility to promote personal and
professional growth, as well as cultural awareness.
UnityPoint Health FOCUS Values
Methodist College is affiliated with UnityPoint Health, and we
seek to demonstrate the organization's FOCUS values:
F - Foster Unity
Use the skills and abilities of each person to enable great teams.
Collaborate across departments, facilities, business units and
regions. Seek to understand and are open to
diverse thoughts and perspectives.
O - Own the Moment
Connect with each person, treating them with courtesy,
compassion, empathy and respect. Enthusiastically engage in
our work. Be accountable for our individual actions and our

7. team performance. Take responsibility for solving problems,
regardless of origin.
C - Champion Excellence
Commit to the best outcomes and highest quality. Have a
relentless focus on exceeding expectations. Believe in sharing
our results, learning from our mistakes and celebrating our
successes.
S - Seize Opportunities
Embrace and promote innovation and transformation. Create
partnerships that improve care delivery in our communities.
Have the courage to challenge the status quo.
2. Please describe why you have chosen a career in healthcare
or human services, and the specialization or field that you are
most interested in pursuing.
What characteristics do you have that will enable you to be
successful in healthcare/human services?
Please include future plans for additional education or
certification.
a. Specialization most interested in pursuing is oncology or ER
nurse
b. Future plans are to be a nurse practitioner

8. 3. What does patient/client/customer/resident advocacy mean to
you? How do you see yourself as an advocate?

9. 4. Describe a time you showed compassion in supporting or
caring for someone else. This could be a friend, family member,
patient, client, or customer.