(Student Name)Miami Regional UniversityDate of EncounterP

(Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Dr. David Trabanco DNP, APRN, AGNP-C,
FNP-C
Soap Note
PATIENT INFORMATION
Name: Mrs
Age: 32 years old
Gender at Birth: Female
Gender Identity: Female
Source: Patient
Allergies: NKDA
Subjective Data
Chief Complaint (CC)
The affected person communicates issues approximately her
right eye. She reviews having a tingling and eating sensation in
his proper eye. Also, She says that the attention creates greater
fluid than expected, and the affected person frequently awakens
with a dried up eyelid.
History of Present Illness (HPI)
The affected person is femmale. She is 32 years of age. The
affected person wears touch focal factors because of having
nearsightedness. Nonetheless, there may be no acknowledged
records of her having a few different illnesses related to
eyesight problems. The precept grievances of the affected
person comprise redness and inflammation of the conjunctiva of
the proper eye, accelerated tear advent and presence of fluid
launch in the attention. Besides, she reviews to having problems
with carrying his touch focal factors. The proper eye started out

to tingle and eat 3 days prior. The affected person tried to
smooth the attention with water and searched for any
unexpected articles which could have brought about the
bothering. Then, at that point, the affected person carried out
Visine eye drops, which in brief mitigated the aggravation. Be
that because it may, the redness did not disappear. The left eye
seems to appearance sound. The affected person reviews to
having notable cleanliness and says that she washes palms
mechanically.
Allergies
NKDA
Past Medical History
The affected person became decided to have nearsightedness
while he became twelve years of age. She normally wore
glasses. Nonetheless, she selected to extrude to touch focal
factors a month prior. The affected person has no set of reviews
of various illnesses related to eyesight. No beyond records of
eye illnesses is recorded.
Family History
The affected person denies having any own circle of relative’s
ancestry pertinent to his condition. The dad has a beyond
packed with controlled high blood pressure. She takes meds and
plays mechanically check-u.s. the clinical clinic. The mom has a
historical past marked via way of means of a summed up
anxiety problem, that's being dealt with treatment. She became
decided to have GAD a 12 months prior. No scientific records
recognized with eye infections may be found.
Surgery
The affected person has no set of reviews of considerable
clinical processes.
Social History
The affected person confesses to smoking and ingesting on
unusual events. She denies illegal remedy use. The affected
person lives together along with his higher 1/2 of and girl. She
fills in as an educator at a college. She denies having
distressing encounters at work. She would not exercise

continually due to a bustling timetable. His well-being degree is
regular. Be that because it may, the historic backdrop of high
blood pressure and mental maladjustment in his own circle of
relatives need to be taken into consideration later on.
Current Medications
The affected person denies taking any meds.
Review of Systems (ROS): The affected person denies having
any new frame problems or weight extrude. He has a regular
starvation and rests now no longer surprisingly. The ranges of
power are everyday also.
Cardiovascular: The affected person denies any chest torments,
palpitations, edema, or dyspnea.
Respiratory: The affected person reviews typically approving of
relaxing. He denies bronchial allergies or hacking.
Dermatology: The affected person denies having any pores and
skin problems. Notwithstanding, he reviews to having redness
and bothering across the proper eye, confessing to contacting
and scouring it previously, then after the truth the presence of
facet results. Generally speaking, she denies any scaling, knots,
or rankles. Mouth, throat, nose, ears: The affected person denies
having a touchy throat, oral or dental problems, nasal clog, or
listening to misfortune.
Eyes: The affected person confesses to having nearsightedness,
which he did not enterprise to restore with any clinical
processes or meds. As according to the affected person, the left
eye isn't always dry or bothered. The proper eye is pink and
bothersome. The affected person moreover reviews to having
obscured imaginative and prescient in his proper eye due to
over the pinnacle tear advent and launch. The hassle centering
is clarified via way of means of nearsightedness, the character
of sight isn't always basically unique.
Genitourinary: The affected person denies any progressions in
criticalness. There isn't anyt any aggravation all through pee.
Gastrointestinal: The affected person denies having i llness or
lack of starvation. She denies having any belly torments.
Outer muscle: The affected person denies joint agony, muscle

torment, squeezing, firmness, or expanding.
Hematologic: The affected person denies pallor or unusual
dying.
Neurologic: The affected person denies cerebral pains,
sluggishness, wooziness, cognitive decline, shortcoming,
seizures, or deadness.
Unfavorably susceptible: The affected person denies having
occasional sensitivities, meals hypersensitivities, or creature
sensitivities. There isn't any own circle of relatives historical
past of sensitivities too.
Mental: The affected person denies misery, self-adverse
contemplations, a snoozing disorder, or anxiety. She denies
having nonstop apprehension or stress.
Objective Data
Vital Signs/Height/Weight Stature: five'8" Weight: one hundred
fifty lb Temperature: 98.five F
Heartbeat: seventy four BPM BP: 117/73
General Appearance
The affected person is a stable searching female and not using
a obtrusive clinical problems. She would not look like in hassle.
The affected person is obvious and compact in her discourse.
She sees all inquiries and solutions them with subsequent to no
problems. Cardiovascular: Heartbeat is every day with regular
charge and beat. No jogs, mumbles, snaps, or rubs present.
There isn't any edema, cyanosis, or clubbing.
Respiratory: The affected person's lungs are clear, there aren't
any sounds. The respiratory is even and has no obstacles.
Stomach: Abdomen is non-sensitive and sensitive. Entrails
sounds are to be had. There isn't any tracking and no masses.
Skin: The affected person's pores and skin is dry and warm.
There aren't any ulcers, wounds, or accidents apparent. The
pores and skin of the proper eyelid is marginally red and
aggravated. There isn't any considerable inflammation of the
eyelid.
Mouth/Throat: Membranes aren't dry. The pharynx is every day.

The oropharynx is clear. Eyes: The conjunctiva of the proper
eye is pink. Fluid watery launch is to be had with inside the
excited eye. Understudies are equal and receptive to light. The
affected person would not seem to have any similarly
disintegration in eyesight. Red reflex is to be had respectively.
There isn't any strabismus or nystagmus present. The
fundoscopic check is typical.
Assessment
Differential Diagnosis
Subconjunctival Hemorrhage. As indicated via way of means of
Mayo Clinic (2017), the subconjunctival drain is a breaking of a
vein with inside the conjunctiva of an eye. This problem
introduces itself as a pink conjunctiva. This form of drain can
occur in view of various motives like a stable wheeze of a hack.
Be that because it may, this problem wears bring forth any
important harm to the individual's eye it typically disappears in
numerous days. The affected person's eye appears pink.
Notwithstanding, distinctive facet results that the affected
person encounters aren't basically related to this problem.
Subconjunctival discharge isn't always joined via way of means
of inflammation or aggravation. Moreover, the redness of the
attention resulting from this affected person isn't always similar
to redness skilled via way of means of people with discharge.
Accordingly, this end may be precluded.
Blepharitis. Blepharitis is the inflammation of the eyelid. The
manifestations of this contamination comprise redness and
disturbance of the eyelid, redness of the attention, swollen eyes,
furthermore, inordinate tearing (National Eye Institute, 2017).
Also, blepharitis is frequently trailed by crusting of the
eyelashes, obscured vision, and foamy tears. Blepharitis is
generally brought about by microscopic organisms or skin
sicknesses, for example, skin break out and scalp dandruff. A
large number of the manifestations of this illness line up with
issues of the patient. Be that as it may, while his eye is red and
aggravated, his eyelid isn't altogether aroused. Additionally, the
hardness of the eyelashes is generally probable brought about

by over the top tearing, which isn't foamy. Blepharitis can be
precluded on account of the eyelid's condition.
Conjunctivitis. Conjunctivitis, in any case called pink eye, is
viewed as the most well-known eye contamination (Centers for
Disease Control and Prevention, 2017). It can happen because
of various reasons, including hypersensitive responses,
microscopic organisms, respiratory diseases, and awful
cleanliness. A wide range of conjunctivitis are described by
redness and irritation of the eye, extreme tear creation, and
release. Nonetheless, a few indications are unique.
Hypersensitive conjunctivitis happens occasionally and is
frequently trailed by different sorts of unfavorably susceptible
responses like roughage fever and asthma. Viral conjunctivitis
generally goes with a typical virus. At last, bacterial
conjunctivitis frequently happens along with different
contaminations. Moreover, ill-advised hand washing can cause
conjunctivitis also. Contact focal points may likewise disturb
the eye in case they are not put away or dealt with
appropriately.
Medical Diagnosis
The launch withinside the affected person's eye is not thick or
foamy, which precludes bacterial conjunctivitis. The affected
person denies having any sicknesses or hypersensitive
responses. Nonetheless, he confesses to carrying touch focal
factors, which he acquired alternatively as of late. Accordingly,
it's far covered to simply accept that the aggravation of the
proper eye is introduced approximately with the aid of using
beside the point focal factor care. It is potential that the
affected person unnoticed to easy the touch focal factors
accurately, which introduced approximately the aggravation of
the proper eye. Along those lines, the realization of
conjunctivitis may be affirmed.
Plan
Orders
Most kinds of conjunctivitis don't need extra treatment (Azari
and Barney, 2013). In any case, to alleviate the aggravation, the

patient should keep on utilizing Visine eye drops and stick to a
stricter handwashing schedule. Additionally, the patient should
change contact focal points and think about buying an alternate
brand of focal point arrangement.
Education
Furnish with nourishment/dietary data.
for 7 days, keep a record, bring the record on the following
encounter with her PCP
of potential complexities like stroke, respiratory
failure, and different issues.
notice signs and side effects, which could show the need to go
to the E.R/U.C. Addressed all pt. questions/concer ns. Pt
expresses comprehension to all
Follow-Up Plans
The following arrangement is essential if the patient keeps on
encountering disturbance in his right eye. For this situation, the
following gathering ought to incorporate extra tests and adhere
to up directions. On the off chance that the issue doesn't
disappear, the patient can take anti-microbials to stop the
irritation.
References
Azari, A. A., & Barney, N. P. (2013). Conjunctivitis: A
systematic review of diagnosis and treatment. Jama, 310(16),
1721-1730.
Centers for Disease Control and Prevention. (2017).
Conjunctivitis. Retrieved from
https://www.cdc.gov/conjunctivitis/index.html
Mayo Clinic. (2017). Subconjunctival hemorrhage. Retrieved
from http://www.mayoclinic.org/diseases-
conditions/subconjunctival- hemorrhage/home/ovc-20231436

National Eye Institute. (2017). Facts about blepharitis.
Retrieved from https://nei.nih.gov/health/blepharitis/blepharitis
Grading Rubric
Student______________________________________
This sheet is to help you understand what we are looking for,
and what our margin remarks might be about on your write ups
of patients. Since at all of the white-ups that you hand in are
uniform, this represents what MUST be included in every write-
up.
1) Identifying Data (___5pts): The opening list of the note. It
contains age, sex, race, marital status, etc. The patient
complaint should be given in quotes. If the patient has more
than one complaint, each complaint should be listed separately
(1, 2, etc.) and each addressed in the subjective and under the
appropriate number.
2) Subjective Data (___30pts.): This is the historical part of the
note. It contains the following:
a) Symptom analysis/HPI(Location, quality , quantity or
severity, timing, setting, factors that make it better or worse,
and associate manifestations.(10pts).
b) Review of systems of associated systems, reporting all
pertinent positives and negatives (10pts).
c) Any PMH, family hx, social hx, allergies, medications related
to the complaint/problem (10pts). If more than one chief
complaint, each should be written u in this manner.
3) Objective Data(__25pt.): Vital signs need to be present.
Height and Weight should be included where appropriate.

a) Appropriate systems are examined, listed in the note and
consistent with those identified in 2b.(10pts).
b) Pertinent positives and negatives must be documented for
each relevant system.
c) Any abnormalities must be fully described. Measure and
record sizes of things (likes moles, scars). Avoid using “ok”,
“clear”, “within normal limits”, positive/ negative, and
normal/abnormal to describe things. (5pts).
4) Assessment (___10pts.): Diagnoses should be clearly listed
and worded appropriately.
5) Plan (___15pts.): Be sure to include any teaching, health
maintenance and counseling along with the pharmacological and
non-pharmacological measures. If you have more than one
diagnosis, it is helpful to have this section divided into separate
numbered sections.
6) Subjective/ Objective, Assessment and Management and
Consistent (___10pts.): Does the note support the appropriate
differential diagnosis process? Is there evidence that you know
what systems and what symptoms go with which complaints?
The assessment/diagnoses should be consistent with the
subjective section and then the assessment and plan. The
management should be consistent with the assessment/
diagnoses identified.
7) Clarity of the Write-up(___5pts.): Is it literate, organized and
complete?
Comments:
Total Score: ____________
Instructor: __________________________________

Guidelines for Focused SOAP Notes
· Label each section of the SOAP note (each body part and
system).
· Do not use unnecessary words or complete sentences.
· Use Standard Abbreviations
S: SUBJECTIVE DATA (information the patient/caregiver tells
you).
Chief Complaint (CC): a statement describing the patient’s
symptoms, problems, condition, diagnosis, physician-
recommended return(s) for this patient visit. The patient’s own
words should be in quotes.
History of present illness (HPI): a chronological description of
the development of the patient's chief complaint from the first
symptom or from the previous encounter to the present. Include
the eight variables (Onset, Location, Duration, Characteristics,
Aggravating Factors, Relieving Factors, Treatment, Severity-
OLDCARTS), or an update on health status since the last
patient encounter.
Past Medical History (PMH): Update current medications,
allergies, prior illnesses and injuries, operations and
hospitalizations allergies, age-appropriate immunization status.
Family History (FH): Update significant medical information
about the patient's family (parents, siblings, and children).
Include specific diseases related to problems identified in CC,
HPI or ROS.
Social History(SH): An age-appropriate review of significant
activities that may include information such as marital status,
living arrangements, occupation, history of use of drugs,
alcohol or tobacco, extent of education and sexual history.
Review of Systems (ROS). There are 14 systems for review.
List positive findings and pertinent negatives in systems
directly related to the systems identified in the CC and

symptoms which have occurred since last visit; (1)
constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3)
ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory,
(6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9-
}.integument (skin and/or breast), (10) neurological, (11)
psychiatric, (12) endocrine, (13) hematological/lymphatic, {14)
allergic/immunologic. The ROS should mirror the PE findings
section.
0: OBJECTIVE DATA (information you observe, assessment
findings, lab results).
Sufficient physical exam should be performed to evaluate areas
suggested by the history and patient's progress since last visit.
Document specific abnormal and relevant negative findings.
Abnormal or unexpected findings should be described. You
should include only the information which was provided in the
case study, do not include additional data.
Record observations for the following systems if applicable to
this patient encounter (there are 12 possible systems for
examination): Constitutional (e.g. vita! signs, general
appearance), Eyes, ENT/mouth, Cardiovascular, Respirator y,
GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric,
Hematological/lymphatic/immunologic/lab testing. The
focused PE should only include systems for which you have
been given data.
NOTE: Cardiovascular and Respiratory systems should be
assessed on every patient regardless of the chief complaint.
Testing Results: Results of any diagnostic or lab testing ordered
during that patient visit.
A: ASSESSMENT: (this is your diagnosis (es) with the
appropriate ICD 10 code)
List and number the possible diagnoses (problems) you have
identified. These diagnoses are the conclusions you have drawn
from the subjective and objective data.
Remember:Your subjective and objective data should support
your diagnoses and your therapeutic plan.

Do not write that a diagnosis is to be "ruled out" rather state the
working definitions of each differential or primary diagnosis
(es).
For each diagnoses provide a cited rationale for choosing this
diagnosis. This rationale includes a one sentence cited
definition of the diagnosis (es) the pathophysiology, the
common signs and symptoms, the patients presenting signs and
symptoms and the focused PE findings and tests results that
support the dx. Include the interpretation of all lab data given in
the case study and explain how those results support your
chosen diagnosis.
P: PLAN (this is your treatment plan specific to this patient).
Each step of your plan must include an EBP citation.
1. Medications write out the prescription including dispensing
information and provide EBP to support ordering each
medication. Be sure to include both prescription and OTC
medications.
2. Additional diagnostic tests include EBP citations to support
ordering additional tests
3. Education this is part of the chart and should be brief, this is
not a patient education sheet and needs to have a reference.
4. Referrals include citations to support a referral
5. Follow up. Patient follow-up should be specified with time or
circumstances of return. You must provide a reference for your
decision on when to follow up.
<table border="0" width="100%" cellpadding="0"
cellspacing="0">
<tr>
<td bgcolor="#000000" style="padding-left:2px; padding-

right:10px; padding-top:2px; padding-bottom:2px">
  Miami
Regional University   (Acct
#3111)</td>
</tr>
</table>


<table border="0" width="100%" cellpadding="0"
cellspacing="0" bgcolor="#C0C0C0">
<tr>
<td width="50%">  Case ID #:
2844-20220119-004
  (Status: NOT Approved)
</td>

<td width="50%">
Date of Service:
1/19/2022 </td>
</tr>
</table>
<table border="0" cellspacing="0" WIDTH="100%"
bordercolor="#99CCFF">
<tr>
<td WIDTH="100%" bgcolor="#000000" colspan="2"
style="border-style: solid; border-width: 2px">
Student Information - Santiesteban Molina,
Osmel</td>
</tr>
<tr>
<td WIDTH="50%" bgcolor="#FFFFFF" align="right">
Semester:</td>
<td WIDTH="50%" bgcolor="#FFFFFF">

Spring

</td>
</tr>
<tr>
Course:</td>

MSN6150C Advanced Practice Pediatrics

</td>
</tr>
<tr>
Preceptor: </td>

TREJO, RODOLFO

</td>
</tr>
<tr>
<td WIDTH="50%" bgcolor="#FFFFFF" align="right"
height="18" valign="top">
Clinical Site:</td>
<td WIDTH="50%" bgcolor="#FFFFFF" height="18">

Neighborhood Family Doctor.Atlantis

</td>
</tr>
<tr>
height="18" valign="top">

Setting Type
Underserved area/population

</td>
</tr>
<tr>
<td WIDTH="100%" bgcolor="#000000" align="right"
colspan="2" style="border-style: solid; border-width: 2px">
size="2">Patient Demographics</td>
</tr>
<tr>
<td bgcolor="#FFFFFF">

Age:</td>

10 years

</td>
</tr>
<tr>
Race
Hispanic
</td>
</tr>
<tr>

size="2">Gender
Female
</td>
</tr>
<tr>
size="2">Insurance
Medicare
</td>
</tr>
<tr>

size="2">Referral
No referral
</td>
</tr>
<tr>
<td valign="top" bgcolor="#000000" colspan="2"
size="2">Clinical Information</td>
</tr>
<tr>
<td bgcolor="#FFFFFF" align="right">
Time with Patient:</td>

15 minutes</td>
</tr>
<tr>
Consult with Preceptor:</td>

5 minutes</td>
</tr>
<tr>
Type of Decision-
Making:</td>

Straightforward
</td>
</tr>
<tr>
Reason for Visit:</td>

Follow-up (Routine)
</td>
</tr>
<tr>

Chief Complaint:</td>

"I have cough and general malaise"
</td>
</tr>
<tr>
Type of HP:</td>

Problem Focused
</td>
</tr>
<tr>
<td bgcolor="#FFFFFF" align="right" valign="top">
Social Problems
Addressed:</td>

Safety Growth &
Development Prevention Education/Language Nutrit
ion/Exercise 
 </td>
</tr>
</table>
<TABLE BORDER="0" CELLPADDING="0"
CELLSPACING="0" WIDTH="100%"
<tr>
<td width="100%" bgcolor="#000000" align="center"
Procedures/Skills
(Observed/Assisted/Performed)</td>
</tr>
<tr>
<td width="100%" bgcolor="#FFFFFF" align="left"
colspan="2">

</td>
</tr>
</table>
<tr>
<td width="100%" bgcolor="#000000" align="center"
ICD-10
Diagnosis Codes</td>
</tr>
<tr>
<td width="10%" bgcolor="#FFFFFF" align="right"
valign="top">
#1 -<font

size="2"> 

</td>
<td width="90%" bgcolor="#FFFFFF" align="left">

J00 - ACUTE NASOPHARYNGITIS [COMMON COLD]

</td>
</tr>
<tr>
<td WIDTH="100%" align="right" bgcolor="#000000"
CPT
Billing Codes</td>
</tr>
<tr>
<td width="10%" bgcolor="#FFFFFF" align="right"
valign="top">

#1 - 

</td>
<td width="90%" bgcolor="#FFFFFF" align="left">

99212 - OFFICE/OP VISIT, EST PT, MEDICALLY
APPROPRIATE HX/EXAM; STRTFWD MED DECISION; 10-
19 MIN

</td>
</tr>
</table>
cellpadding="1">
<tr>
colspan="2" style="border-style: solid; border-width: 2px"

Birth & Delivery</td>
</tr>
</table>
cellpadding="1">
<tr>
colspan="2" style="border-style: solid; border-width: 2px"
Medications</td>
</tr>
<tr>
<td width="50%" bgcolor="#FFFFFF" align="right">
# OTC Drugs taken
regularly:</td>

valign="top">

0</td>
</tr>
<tr>
# Prescriptions currently
prescribed:</td>
valign="top">

0</td>
</tr>
<tr>
# New/Refilled Prescriptions This
Visit:</td>

valign="top">

3</td>
</tr>
<tr>
valign="top">

Types of New/Refilled Prescriptions This
Visit: 
Analgesic/Antipyretic - Acetaminophen combinations ENT
- Decongestants/antihistamine combinations ENT -
Expectorants 
 </td>
valign="top">

Adherence Issues with
Medications: 
 </td>
</tr>
</table>
CELLSPACING="0" WIDTH="100%" bgcolor="#FFFFFF">
<tr>
colspan="2" bordercolor="#99CCFF" style="border-style: solid;
border-width: 2px">
Other
Questions About This Case</td>
</tr>

<tr>
height="18">
Patient's Primary
Language:</td>

Spanish

</td>
</tr>
<tr>
height="18">
Smoking Assessment:</td>

Never

</td>
</tr>
<tr>
height="18">
Advanced Directive:</td>

No

</td>
</tr>
<tr><td bgcolor='#FFFFFF' valign = 'top' width='50%'>Packs per
day:</td><td bgcolor='#FFFFFF'></td></tr>
</table>

CELLSPACING="0" WIDTH="100%" bgcolor="#FFFFFF">
<tr>
<td width="100%" bgcolor="#000000" align="left"
valign="top" colspan="2" bordercolor="#99CCFF"
size="2">Clinical Notes</td>
</tr>
<tr>
valign="top" colspan="2">


</td>

(Student Name)Miami Regional UniversityDate of EncounterP

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