Soap Arthritis Rheumatoid.docx
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The patient, a 45-year-old Hispanic female, presented with a chief complaint of joint pain and stiffness for 6 months. She reported pain and swelling in her hands, wrists, knees, and feet. A physical exam revealed tender and swollen joints, limited range of motion, and morning stiffness lasting over 30 minutes. Laboratory tests showed elevated inflammatory markers. She was diagnosed with rheumatoid arthritis (ICD-10 M05.9). Treatment includes naproxen for pain and inflammation along with methotrexate and folic acid supplements. Close follow up is needed to monitor symptoms and medication effectiveness.
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Search reputable local and national media for a man-made disaster to discuss.
Search for critical instances such as: hostage situations, mass shootings, multiple-vehicle or mass transit accidents with multiple critical injuries, and disease outbreaks.
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NUR 634 SOAP Note Guide and Template
Patient SOAP Note Charting Procedures
S = Subjective
O = Objective
A = Assessment
P = Plan
Subjective: Information the patient tells the treating team or patient advocate. Symptoms, not signs. These are typically not measurable, such as pain, nausea, and tingling, hence the term “subjective” as opposed to “objective”. Normally, the practitioner is not aware of this information until the patient provides it.
Objective: Information gathered by the treating team or provider which is typically observable and measurable, hence “objective” as opposed to “subjective”. Normally, the patient is not aware of this information until the practitioner elicits it. This might include, for example, ranges of motion, body temperature, blood pressure, the presence of a skin rash or wound, comments about the patient’s posture or gait, and the results of examination procedures and testing.
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Plan: Based on the assessment or diagnosis, the treatment or therapeutic plan must be outlined. This may include both short and long term plans. It is important to record not only passive therapy, such as an injection, a prescription, a spinal manipulation or a massage, but also active therapy such as home care advice, exercises or other recommendations. All treatment planned or delivered must be recorded.
SOAP NOTE TEMPLATE
**Please delete the instructions in each section prior to submitting the assignment
Student Name: Date: Course:
Subjective:
Patient Demographics: (age, gender, gender identity, ethnicity, etc.)
Chief Complaint: “quote patient”
History of Present illness: (Be sure to tell the “story” of the cc using the 7 attributes or OLDCARTS)
PMH: dates in reverse chronological order.
PSH: surgery dates in reverse chronological order.
Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies
Untoward Medication Reactions: include type ...
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Do Not change the template.
Do use the template located in the Doc Sharing. This is the explanation of the template…this is not the template.
READ every line of this document please.
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Purpose: To explain 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. DO NOT INCLUDE IN NOTE
Subjective data value @ 15 points
SUBJECTIVE DATA: What the patient tells you but organized by you in logical fashion
Chief Complaint (CC): One to three words explaining why patient came to clinic value 1 point
History of Present Illness (HPI): Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, gender. (Example: 34-year-old AA male) Must include the 7 attributes of each principal symptom: value 7 points hint: OLD CART
Write your paragraph in the order of old cart & chart as well if missing paragraph -3.5 if missing list -3.5
Onset
Location
Duration
Characteristics
Aggravating Factors
Relieving Factors
Treatments/Therapies
Each of these are valued at 0.5 points (maximum 4 points)
Medications: list each one by name with dosage and frequency
Allergies: include specific reactions to medications, foods, insects, environmental
Past Medical History (PMH): Illnesses, hospitalizations, risky sexual behaviors. Include childhood illnesses
Past Surgical History (PSH): Dates, indications and types of operations
OB/GYN History: (if applicable) Obstetric history, menstrual history, methods of contraception and sexual function
Personal/Social History: Tobacco use, Alcohol use, Drug use. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits. Pediatrics: school status, parental smoking hx, birth history etc
Immunizations: Last Tdp, Flu, pneumonia, etc. Pediatrics- (per pediatric schedule for age)
Family History: Parents, Grandparents, siblings, children
Review of Systems: Go Head to toe. Cover each system that covers the Chief Complaint, History of Present Illness and History (this includes the systems that address any previous diagnoses). YOU DO NOT NEED TO DO THEM ALL UNLESS YOU ARE DOING a TOTAL H&P. Remember, this is what the patient tells you. Delete the system if not addressing. DO NOT put wnl or no complaints be specific. Value 3 points
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Search reputable local and national media for a man-made disaster to discuss.
Search for critical instances such as: hostage situations, mass shootings, multiple-vehicle or mass transit accidents with multiple critical injuries, and disease outbreaks.
In your initial post, describe the incident and address the following:
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NUR 634 SOAP Note Guide and Template
Patient SOAP Note Charting Procedures
S = Subjective
O = Objective
A = Assessment
P = Plan
Subjective: Information the patient tells the treating team or patient advocate. Symptoms, not signs. These are typically not measurable, such as pain, nausea, and tingling, hence the term “subjective” as opposed to “objective”. Normally, the practitioner is not aware of this information until the patient provides it.
Objective: Information gathered by the treating team or provider which is typically observable and measurable, hence “objective” as opposed to “subjective”. Normally, the patient is not aware of this information until the practitioner elicits it. This might include, for example, ranges of motion, body temperature, blood pressure, the presence of a skin rash or wound, comments about the patient’s posture or gait, and the results of examination procedures and testing.
Assessment: The diagnosis. This must be documented prior to the rendering or delivery of any treatment. Symptom code can be documented as assessment when pending final diagnosis such as Chest pain vs. MI.
Plan: Based on the assessment or diagnosis, the treatment or therapeutic plan must be outlined. This may include both short and long term plans. It is important to record not only passive therapy, such as an injection, a prescription, a spinal manipulation or a massage, but also active therapy such as home care advice, exercises or other recommendations. All treatment planned or delivered must be recorded.
SOAP NOTE TEMPLATE
**Please delete the instructions in each section prior to submitting the assignment
Student Name: Date: Course:
Subjective:
Patient Demographics: (age, gender, gender identity, ethnicity, etc.)
Chief Complaint: “quote patient”
History of Present illness: (Be sure to tell the “story” of the cc using the 7 attributes or OLDCARTS)
PMH: dates in reverse chronological order.
PSH: surgery dates in reverse chronological order.
Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies
Untoward Medication Reactions: include type ...
APA Title page, running head, page numbers, reference sheet. Use L.docx
APA Title page, running head, page numbers, reference sheet. Use Level 1 and 2 headings to make identifying the components of the paper easier. – 5 points after grade calculated from rubric.
TO be successful in the clinical setting do the following:
You need a APA cover sheet, running head and reference page for anything you turn in (Journal, SOAP note, Time Log).
Do Not change the template.
Do use the template located in the Doc Sharing. This is the explanation of the template…this is not the template.
READ every line of this document please.
You must site 2 journal articles in addition to Epocrates/Medscape and text book failure to do so is -10 points outside of the rubric.
All grades are final. No revisions. Do not ask for revisions of SOAP grades.
Nurse Practitioner SOAP Notes
Purpose: To explain 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. DO NOT INCLUDE IN NOTE
Subjective data value @ 15 points
SUBJECTIVE DATA: What the patient tells you but organized by you in logical fashion
Chief Complaint (CC): One to three words explaining why patient came to clinic value 1 point
History of Present Illness (HPI): Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, gender. (Example: 34-year-old AA male) Must include the 7 attributes of each principal symptom: value 7 points hint: OLD CART
Write your paragraph in the order of old cart & chart as well if missing paragraph -3.5 if missing list -3.5
Onset
Location
Duration
Characteristics
Aggravating Factors
Relieving Factors
Treatments/Therapies
Each of these are valued at 0.5 points (maximum 4 points)
Medications: list each one by name with dosage and frequency
Allergies: include specific reactions to medications, foods, insects, environmental
Past Medical History (PMH): Illnesses, hospitalizations, risky sexual behaviors. Include childhood illnesses
Past Surgical History (PSH): Dates, indications and types of operations
OB/GYN History: (if applicable) Obstetric history, menstrual history, methods of contraception and sexual function
Personal/Social History: Tobacco use, Alcohol use, Drug use. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits. Pediatrics: school status, parental smoking hx, birth history etc
Immunizations: Last Tdp, Flu, pneumonia, etc. Pediatrics- (per pediatric schedule for age)
Family History: Parents, Grandparents, siblings, children
Review of Systems: Go Head to toe. Cover each system that covers the Chief Complaint, History of Present Illness and History (this includes the systems that address any previous diagnoses). YOU DO NOT NEED TO DO THEM ALL UNLESS YOU ARE DOING a TOTAL H&P. Remember, this is what the patient tells you. Delete the system if not addressing. DO NOT put wnl or no complaints be specific. Value 3 points
General: any recent weight changes, weakness, fatigue,.
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Progress notes and patient records are the medical translator's bread and butter, but this doesn't prevent even the most experienced medical translators from getting burnt. We'll take a closer look at the SOAP (Subjective, Objective, Assessment, Plan) format to understand how doctors think. We'll use the tool to understand why "BS" could mean "blood sugar," "breath sounds," or "bowel sounds." We'll also build a kit of multilingual resources for the review of systems, lab reports, etc. Finally, we'll address capturing succinct source-language style in a translation that is meaningful and not unduly conservative.
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1) This soap note document outlines the typical sections and information included in a soap note for a patient with diabetes mellitus. It includes sections for identifying data, subjective data, objective data, assessment, and plan.
2) The subjective section includes symptoms, review of systems, past medical history, family history, social history, and allergies/medications as they relate to the complaint.
3) The objective section includes vital signs, physical exam findings described in detail for relevant systems, and any abnormalities fully described.
Comprehensive SOAP TemplatePatient Initials _______Age ___.docx
Comprehensive SOAP Template
Patient 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= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= 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.
History 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. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications: 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: Includelast Tdp, Flu, pneumonia, etc.
Significant 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/Immunolog.
Comprehensive SOAP TemplateThis template is for a full history.docx
Comprehensive SOAP Template
This template is for a full history and physical. For this course include only areas that are related to the case.
Patient 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= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= treatments previously tried – response? Why discontinued?
S= severity
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Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.
History 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 (e.g., 34-year-old AA male). You must include the seven attributes ofeach principal symptom in paragraph form not a list:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications: 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. Identify if it is an allergy or intolerance.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations.
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and risky sexual behaviors.
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: Includelast Tdap, Flu, pneumonia, etc.
Significant Family History: Include history of parents, grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference.
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 so 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:
Mu.
Cycle brief
Zelmac® is a new treatment that addresses the underlying cause of IBS by working on the brain-gut axis as a selective 5HT4 agonist. It provides global multisymptom relief by normalizing GI function in 3 ways. Clinical trials show Zelmac® provides rapid and sustained relief of abdominal pain, altered bowel movements, and overall well-being for patients with C-IBS. Unlike traditional therapies, Zelmac® meets the need for an ideal C-IBS treatment by addressing the underlying pathophysiology and providing specific relief of the key ABC symptoms of the condition.
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For this assignment, you are to complete a
clinical case - narrated PowerPoint report
that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.
You are to approach this clinical scenario as if it is a real patient in the clinical setting.
Instructions:
Step 1
- Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.
Step 2
- Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.
Step 3
- Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.
Example of Steps 1 - 3:
You decided on Angina after reading the clinical case scenario (Step 1)
Review of Symptoms (list of classic symptoms):
CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone
GI: indigestion, heartburn, nausea, cramping
Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth
Resp: shortness of breath
Musculo: weakness
Step 4
– Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations.
Example of Step 4:
You determined the patient has Angina in Step 1
Physical Examination (list of classic exam findings):
CV: RRR, murmur grade 1/4
Resp: diminished breath sounds left lower lobe
Step 5
- Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.
Step 6
- Develop a treatment plan for the diagnoses.
Only
use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan
must
address the following:
a) Medications (include the dosage in mg/kg, frequency, route, and the number of days)
b) Laboratory tests ordered (include why ordered and what the results of the test may indicate)
c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate)
d) Vaccines administered this visit & vaccine administration forms given,
e) Non-pharmacological treatments
f) Patient/Family education including preventive care
g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)
h) Follow-up appointment wit.
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SOAP NOTE TEMPLATE
Please role play with a volunteer family member or friend to complete this assignment. You will focus on a respiratory disorder and gather data to complete an episodic SOAP note. You will include evidence-based practice guidelines in the management plan, and include rationales for differential diagnoses (cite source). Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice The term “Rule Out…” cannot be used as a diagnosis. Please describe appearance of area assessed and refrain from using the term “normal” when documenting this note. Please note that requirements for SOAP notes may differ across NP courses.
I. Subjective Data
A. Chief Complain (CC):
B. History of Present Illness (HPI):
C. Last Menstrual Period (LMP- if applicable)
D. Allergies:
E. Past Medical History:
F. Family History:
G. Surgery History:
H. Social History (alcohol, drug or tobacco use):
I. Health Maintenance: ( include last PAP/MAM, immunizations, colonoscopy, PSA, last eye & physical exam, etc.)
J. Lifestyle Patterns (include spiritual beliefs, behaviors, and traditional practices)
K. Current medications:
L. Review of Systems (Remember to inquire about body systems relevant to the chief complaint & HPI)
II. Objective Data
Please remember to include an assessment of all relevant systems based on the CC and HPI. The following systems are required in all SOAP notes. You will proceed to assess additional pertinent systems.
Vital Signs/ Height/Weight:
General Appearance:
HEART:
RESP:
A. Assessment
Differential Diagnosis (include rationales and cite source)
1.
2.
3.
Medical Diagnosis (include ICD 10 codes)
1.
B: PLAN
1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided
2. Diagnostic testing
3. Problem oriented education
4. Health Promotion/Maintenance Needs
5. Cultural & Life span considerations
6. Referrals
Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit ---F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic)
Please include CPT Code (level of visit)
References: Please include at least 3 evidence-based sources in APA format.
SOAP NOTE TEMPLATE
Please role play with a volunteer family member or friend to complete this assignment. You will
focus on a respiratory disorder and gather data to complete an episodic SOAP note. You will
include evidence
-
based practice guidelines in the management plan,
and include rationales for
differential diagnoses (cite .
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This document provides instructions for writing a 500-750 word public health paper on a global health topic. It outlines formatting requirements and content that must be included. The paper must have an introduction paragraph with 3 pieces of background on the selected country. It then requires 1-2 paragraphs describing a specific health problem in that country, including risk factors, consequences, and 2 epidemiological data points. Next, it wants 1 paragraph on prevention strategies for the issue. It concludes by requiring an original health goal statement and a paragraph on the impact of globalization on worldwide health.
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For this assignment, you are to complete a
clinical case - narrated PowerPoint report
that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.
You are to approach this clinical scenario as if it is a real patient in the clinical setting.
Instructions:
Step 1
- Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.
Step 2
- Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.
Step 3
- Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.
Example of Steps 1 - 3:
You decided on Angina after reading the clinical case scenario (Step 1)
Review of Symptoms (list of classic symptoms):
CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone
GI: indigestion, heartburn, nausea, cramping
Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth
Resp: shortness of breath
Musculo: weakness
Step 4
– Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations.
Example of Step 4:
You determined the patient has Angina in Step 1
Physical Examination (list of classic exam findings):
CV: RRR, murmur grade 1/4
Resp: diminished breath sounds left lower lobe
Step 5
- Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.
Step 6
- Develop a treatment plan for the diagnoses.
Only
use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan
must
address the following:
a) Medications (include the dosage in mg/kg, frequency, route, and the number of days)
b) Laboratory tests ordered (include why ordered and what the results of the test may indicate)
c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate)
d) Vaccines administered this visit & vaccine administration forms given,
e) Non-pharmacological treatments
f) Patient/Family education including preventive care
g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)
h) Follow-up appointment with a.
the disease is Acute Respiratory Distress Syndrome (ARDS). .docx
the disease is Acute Respiratory Distress Syndrome (
ARDS
).
The paper should be 2-3 pages in length and follow APA 7 style.
Your paper should discuss the following:
Pathology
: Describe the disease or condition, discuss the incidence/prevalence, and identify risk factors
Clinical manifestations
: Describe the signs and symptoms of the disease
Diagnostic tools
: Identify and describe any thoracic imaging that are useful in the diagnosis of the disease
Treatment
: Describe in detail potential treatment options and outcomes
Disease management
: Identify any published guidelines for the long-term treatment of the disease
Patient education
: Describe how the RCP can educate a patient with the established diagnosis
Special considerations
: Identify any points that are distinct to the disease
Please use at minimum, Egan’s Fundamentals of Respiratory Care textbook, as a resource for the project. This is an opportunity for you to be creative! Please include visual aids (chest x-ray images, graphs, charts, etc.) that support your findings.
.
Soap Note 2 Chronic Conditions (asthma)Pick any Chronic Dise.docx
Soap Note 2 Chronic Conditions (asthma)
Pick any Chronic Disease from Weeks 6-10 (asthma)
Must use the sample template for your soap note
, keep this template for when you start clinicals.
Follow the MRU Soap Note Rubric as a guide
Use APA format and must include a minimum of 2 Scholarly Citations.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
The use of the templates is ok with regards to Turn it in, but the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient.
(Student Name)
Miami Regional
University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor:
Patricio Bidart MSN, APRN, FNP-C
Soap Note #
____ Main Diagnosis ______________
PATIENT INFORMATION
Name
:
Age
:
Gender at Birth:
Gender Identity
:
Source
:
Allergies
:
Current Medications:
•
PMH:
Immunizations:
Preventive Care
:
Surgical History
:
Family History
:
Social History
:
Sexual Orientation
:
Nutrition History
:
Subjective Data:
Chief
Complaint
:
Symptom analysis/HPI:
The patient is …
Review of Systems (ROS)
(This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL
:
NEUROLOGIC
:
HEENT
:
RESPIRATORY
:
CARDIOVASCULAR
:
GASTROINTESTINAL
:
GENITOURINARY
:
MUSCULOSKELETAL
:
SKIN
:
Objective Data:
VITAL SIGNS:
GENERAL APPREARANCE
:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example :
“Pt came in to our clinic c/o of ear
pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that
etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.
Differential diagnosis
(minimum 3)
-
-
-
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
• - • -
Pharmacological treatment:
-
Non-Pharmacologic treatment
:
Education
(provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References
(in APA Style)
Examples
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
(25th ed.). Print (The 5-Minute Consult Series).
.
Case Report Writing Tips
Writing a case report is an integral part of scientific writing because:
It proposes a new hypothesis in Medical Science
Shares new and rare clinical observations that can be the focus of a larger clinical study
Helps to publicize information about a rare disease
https://www.cognibrain.com/tips-for-writing-an-effective-case-report/
[Type here]Rasmussen University Be sure all outside so
[Type here]
Rasmussen University
Be sure all outside sources are cited using current APA style.
Write from nursing perspective
In text citation
Three references
Used the medical diagnosis (gestational diabetes) by giving their pathophysiology, causes, risk factors, signs and symptom/clinical, complication, and treatment and fill all the concept map below
CONCEPT MAP
Pathophysiology – (to the cellular level)
Medical Diagnosis
Preterm Labor
Signs & Symptoms/Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies) (What symptoms does your client present with?)
Complications
Treatment (Medical, medications, intervention and supportive)
Causes/Risk Factors (chemical, environmental, psychological, physiological and genetic)
.
REMEMBER THAT THE EXPECTED OUTCOMES MUST BE MEASURABLE. THE INTERVENTIONS ARE WHAT YOU DO TO ASSURE THE OUTCOME AND THE CLIENT’S RESPONSE IS SPECIFICALLY HER RESPONSE.
PLAN OF CARE:Use your top two priorities
NANDA NURSING DIAGNOSIS use NANDA definition
Expected outcomes of care (Goals)
Interventions
Patient response
Goal evaluation
NRS DX:
Problem Statement:
R/T: (What is the cause of the symptom)
Manifested by: (Specific symptoms)
Short term goal: Create a SMART goal that relates to hospital stay/shift/day.
Long term goal: Create a SMART goal that is appropriate for discharge.
This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)
Interventions for short-term goal:
1.
2.
3.
Interventions for long term goal:
1.
2.
3.
Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch)
Reassess for short-term goal:
1.
2.
3.
Reassess for long-term goal:
1.
2.
3.
Was it met or not met there is no partially met.
Summer 2021 JM 9
[Type here]
Be sure all outside sources are cited using current APA style.
Write from
nursing
perspective
In text citation
Three references
Used the medical diagnosis
(gestational
diabetes)
by giving their pathophysiology, causes, risk factors, signs and
symptom/clinical, complication, and treatment
and
fill all the concept map
below
CON
CEPT MAP
Pathophysiology
–
(to the cellular level)
Medical Diagnosis
Preterm Labor
Signs &
Symptoms/
Clinical
Manifestations
(all data subjective
and objective: labs, radiology, all
diagnostic
studies) (
What symptoms
does your client present with?)
Complications
Treatment
(Medical, medications,
intervention and supportive)
Causes/
Risk Facto
rs
(chemical,
environmental, psychological, physiological
and genetic
)
[Type here]
Be sure all outside sources are cited using current APA style.
Write from nursi ...
Lecture 3
The document discusses best practices for documenting patient history and exams, including:
- Recording the full date, time, demographics, and chief complaint for every exam.
- Asking follow up questions to the chief complaint using mnemonics like TADD, OPQRST, and OLD CARTS to fully understand symptoms.
- Documenting details of the history of present illness by addressing at least 4 of 9 symptom characteristics for comprehensive exams.
- Using "telegraphing" to shorten notes while maintaining meaning. The chief complaint should always be in the patient's own words within quotation marks.
Social What directed your interest to this.docx
The document discusses why the person is interested in social work. They grew up seeing friends' parents addicted to drugs and in foster care, directing their interest to help address problems like drugs, poverty, and lack of guidance. Their goals are to open a teenage shelter and drug rehab programs one day. They believe their dedication enables them to study and practice social work to help address important social issues.
Soap notes will be uploaded to Moodle and put through.docx
This soap note documents a visit for a 65-year-old male patient complaining of headaches for the past two weeks. On examination, the patient's blood pressure was elevated on multiple readings. The assessment is essential (primary) hypertension. The plan includes starting hydrochlorothiazide 25 mg daily, as well as lifestyle modifications and follow up with his primary care provider in one week to evaluate blood pressure control. No referrals are needed at this time.
Social Poverty.docx
Poverty is one of four social issues that students must write a 400-450 word mini-essay about for a class assignment. The assignment requires students to choose three social issues to write about, with the fourth essay topic being on poverty. All four mini-essays must be combined into a single document and meet the 1,200 total word count for the assignment.
Social Disorganization.docx
Social disorganization refers to the inability of a community to realize common values or solve emerging problems. Socially disorganized neighborhoods typically have high rates of poverty, residential mobility, and ethnic heterogeneity which undermine the ability of a community to exercise informal social control. Research shows that socially disorganized areas tend to have weaker social ties between neighbors and higher crime rates.
SOC101 Assignment Sheet Interview.docx
This document provides instructions for a SOC101 assignment where students are asked to interview someone over age 65 about their experiences with age and happiness. The interview is meant to help students connect course concepts to real life by gaining perspectives from other demographics. Students are given qualitative questions to ask and should write a substantive report summarizing the conversation rather than providing a full transcript, keeping the subject anonymous.
Slide 1 Title Page Slide 2 3.docx
This presentation discusses the diagnosis and treatment of bipolar disorder and major depressive disorder based on a case scenario. It outlines the diagnostic criteria and symptoms of bipolar disorder and major depressive disorder, describing treatment strategies and interventions for each, such as medications and therapies. The presentation concludes with a reference page.
Social media sites have recently drew decision attention and influenced.docx
Employers are increasingly using social media to evaluate potential job candidates, with sites like LinkedIn and Facebook providing profiles and information to aid hiring decisions. However, social media may not always accurately reflect candidates and could include fake or misleading information, making it difficult for employers to properly assess candidates and determine the right fit based on online profiles alone. More research is needed to understand how social media has impacted hiring and how employers can mitigate risks of relying too heavily on digital profiles.
Smart Desk For Elderly.docx
This document discusses researching scholarly references related to designing a smart desk for the elderly to address needs and find similar existing designs. It requests 8 articles on the project topic or similar topics be cited and summarized in 3-4 sentences each. An abstract and analysis are also needed. The tasks outlined in another file have not all been completed yet, but existing research is related to the smart desk project and more details still need to be found.
Social cognition is the mental activity relating to social.docx
Social cognition helps us understand our own and other people's behavior through mental processes. It allows for quick thinking through cognitive heuristics but can sometimes lead to errors in judgment. Schemas and attitudes can change through accommodation when new information is incorporated or remain the same through assimilation when new information is fit into the existing schema. Cognitive heuristics used in social judgments can influence those judgments and possibly lead them to be incorrect.
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Comprehensive SOAP TemplatePatient Initials _______Age ___.docx
Comprehensive SOAP Template
Patient 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= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= 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.
History 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. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications: 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: Includelast Tdp, Flu, pneumonia, etc.
Significant 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/Immunolog.
Comprehensive SOAP TemplateThis template is for a full history.docx
Comprehensive SOAP Template
This template is for a full history and physical. For this course include only areas that are related to the case.
Patient 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= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= 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.
History 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 (e.g., 34-year-old AA male). You must include the seven attributes ofeach principal symptom in paragraph form not a list:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications: 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. Identify if it is an allergy or intolerance.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations.
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and risky sexual behaviors.
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: Includelast Tdap, Flu, pneumonia, etc.
Significant Family History: Include history of parents, grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference.
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 so 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:
Mu.
Cycle brief
Zelmac® is a new treatment that addresses the underlying cause of IBS by working on the brain-gut axis as a selective 5HT4 agonist. It provides global multisymptom relief by normalizing GI function in 3 ways. Clinical trials show Zelmac® provides rapid and sustained relief of abdominal pain, altered bowel movements, and overall well-being for patients with C-IBS. Unlike traditional therapies, Zelmac® meets the need for an ideal C-IBS treatment by addressing the underlying pathophysiology and providing specific relief of the key ABC symptoms of the condition.
For this assignment, you are to complete aclinical case - narr.docx
For this assignment, you are to complete a
clinical case - narrated PowerPoint report
that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.
You are to approach this clinical scenario as if it is a real patient in the clinical setting.
Instructions:
Step 1
- Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.
Step 2
- Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.
Step 3
- Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.
Example of Steps 1 - 3:
You decided on Angina after reading the clinical case scenario (Step 1)
Review of Symptoms (list of classic symptoms):
CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone
GI: indigestion, heartburn, nausea, cramping
Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth
Resp: shortness of breath
Musculo: weakness
Step 4
– Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations.
Example of Step 4:
You determined the patient has Angina in Step 1
Physical Examination (list of classic exam findings):
CV: RRR, murmur grade 1/4
Resp: diminished breath sounds left lower lobe
Step 5
- Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.
Step 6
- Develop a treatment plan for the diagnoses.
Only
use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan
must
address the following:
a) Medications (include the dosage in mg/kg, frequency, route, and the number of days)
b) Laboratory tests ordered (include why ordered and what the results of the test may indicate)
c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate)
d) Vaccines administered this visit & vaccine administration forms given,
e) Non-pharmacological treatments
f) Patient/Family education including preventive care
g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)
h) Follow-up appointment wit.
SOAP NOTE TEMPLATEPlease role play with a volunteer family mem.docx
SOAP NOTE TEMPLATE
Please role play with a volunteer family member or friend to complete this assignment. You will focus on a respiratory disorder and gather data to complete an episodic SOAP note. You will include evidence-based practice guidelines in the management plan, and include rationales for differential diagnoses (cite source). Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice The term “Rule Out…” cannot be used as a diagnosis. Please describe appearance of area assessed and refrain from using the term “normal” when documenting this note. Please note that requirements for SOAP notes may differ across NP courses.
I. Subjective Data
A. Chief Complain (CC):
B. History of Present Illness (HPI):
C. Last Menstrual Period (LMP- if applicable)
D. Allergies:
E. Past Medical History:
F. Family History:
G. Surgery History:
H. Social History (alcohol, drug or tobacco use):
I. Health Maintenance: ( include last PAP/MAM, immunizations, colonoscopy, PSA, last eye & physical exam, etc.)
J. Lifestyle Patterns (include spiritual beliefs, behaviors, and traditional practices)
K. Current medications:
L. Review of Systems (Remember to inquire about body systems relevant to the chief complaint & HPI)
II. Objective Data
Please remember to include an assessment of all relevant systems based on the CC and HPI. The following systems are required in all SOAP notes. You will proceed to assess additional pertinent systems.
Vital Signs/ Height/Weight:
General Appearance:
HEART:
RESP:
A. Assessment
Differential Diagnosis (include rationales and cite source)
1.
2.
3.
Medical Diagnosis (include ICD 10 codes)
1.
B: PLAN
1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided
2. Diagnostic testing
3. Problem oriented education
4. Health Promotion/Maintenance Needs
5. Cultural & Life span considerations
6. Referrals
Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit ---F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic)
Please include CPT Code (level of visit)
References: Please include at least 3 evidence-based sources in APA format.
SOAP NOTE TEMPLATE
Please role play with a volunteer family member or friend to complete this assignment. You will
focus on a respiratory disorder and gather data to complete an episodic SOAP note. You will
include evidence
-
based practice guidelines in the management plan,
and include rationales for
differential diagnoses (cite .
Essential tips for handling cardiology coding and billing1
Essential Tips for Handling Cardiology Coding and Billing
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#guidelinesforcardiology #cardiologypractices #cardiologybillingandcoding #MBC #documentationerrors #cardiologymedicalbillingandcoding #claimsdenials
Public Health Question.docx
This document provides instructions for writing a 500-750 word public health paper on a global health topic. It outlines formatting requirements and content that must be included. The paper must have an introduction paragraph with 3 pieces of background on the selected country. It then requires 1-2 paragraphs describing a specific health problem in that country, including risk factors, consequences, and 2 epidemiological data points. Next, it wants 1 paragraph on prevention strategies for the issue. It concludes by requiring an original health goal statement and a paragraph on the impact of globalization on worldwide health.
For this assignment, you are to complete aclinical case - narrat.docx
For this assignment, you are to complete a
clinical case - narrated PowerPoint report
that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.
You are to approach this clinical scenario as if it is a real patient in the clinical setting.
Instructions:
Step 1
- Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.
Step 2
- Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.
Step 3
- Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.
Example of Steps 1 - 3:
You decided on Angina after reading the clinical case scenario (Step 1)
Review of Symptoms (list of classic symptoms):
CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone
GI: indigestion, heartburn, nausea, cramping
Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth
Resp: shortness of breath
Musculo: weakness
Step 4
– Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations.
Example of Step 4:
You determined the patient has Angina in Step 1
Physical Examination (list of classic exam findings):
CV: RRR, murmur grade 1/4
Resp: diminished breath sounds left lower lobe
Step 5
- Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.
Step 6
- Develop a treatment plan for the diagnoses.
Only
use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan
must
address the following:
a) Medications (include the dosage in mg/kg, frequency, route, and the number of days)
b) Laboratory tests ordered (include why ordered and what the results of the test may indicate)
c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate)
d) Vaccines administered this visit & vaccine administration forms given,
e) Non-pharmacological treatments
f) Patient/Family education including preventive care
g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)
h) Follow-up appointment with a.
the disease is Acute Respiratory Distress Syndrome (ARDS). .docx
the disease is Acute Respiratory Distress Syndrome (
ARDS
).
The paper should be 2-3 pages in length and follow APA 7 style.
Your paper should discuss the following:
Pathology
: Describe the disease or condition, discuss the incidence/prevalence, and identify risk factors
Clinical manifestations
: Describe the signs and symptoms of the disease
Diagnostic tools
: Identify and describe any thoracic imaging that are useful in the diagnosis of the disease
Treatment
: Describe in detail potential treatment options and outcomes
Disease management
: Identify any published guidelines for the long-term treatment of the disease
Patient education
: Describe how the RCP can educate a patient with the established diagnosis
Special considerations
: Identify any points that are distinct to the disease
Please use at minimum, Egan’s Fundamentals of Respiratory Care textbook, as a resource for the project. This is an opportunity for you to be creative! Please include visual aids (chest x-ray images, graphs, charts, etc.) that support your findings.
.
Soap Note 2 Chronic Conditions (asthma)Pick any Chronic Dise.docx
Soap Note 2 Chronic Conditions (asthma)
Pick any Chronic Disease from Weeks 6-10 (asthma)
Must use the sample template for your soap note
, keep this template for when you start clinicals.
Follow the MRU Soap Note Rubric as a guide
Use APA format and must include a minimum of 2 Scholarly Citations.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
The use of the templates is ok with regards to Turn it in, but the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient.
(Student Name)
Miami Regional
University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor:
Patricio Bidart MSN, APRN, FNP-C
Soap Note #
____ Main Diagnosis ______________
PATIENT INFORMATION
Name
:
Age
:
Gender at Birth:
Gender Identity
:
Source
:
Allergies
:
Current Medications:
•
PMH:
Immunizations:
Preventive Care
:
Surgical History
:
Family History
:
Social History
:
Sexual Orientation
:
Nutrition History
:
Subjective Data:
Chief
Complaint
:
Symptom analysis/HPI:
The patient is …
Review of Systems (ROS)
(This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL
:
NEUROLOGIC
:
HEENT
:
RESPIRATORY
:
CARDIOVASCULAR
:
GASTROINTESTINAL
:
GENITOURINARY
:
MUSCULOSKELETAL
:
SKIN
:
Objective Data:
VITAL SIGNS:
GENERAL APPREARANCE
:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example :
“Pt came in to our clinic c/o of ear
pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that
etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.
Differential diagnosis
(minimum 3)
-
-
-
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
• - • -
Pharmacological treatment:
-
Non-Pharmacologic treatment
:
Education
(provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References
(in APA Style)
Examples
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
(25th ed.). Print (The 5-Minute Consult Series).
.
Case Report Writing Tips
Writing a case report is an integral part of scientific writing because:
It proposes a new hypothesis in Medical Science
Shares new and rare clinical observations that can be the focus of a larger clinical study
Helps to publicize information about a rare disease
https://www.cognibrain.com/tips-for-writing-an-effective-case-report/
[Type here]Rasmussen University Be sure all outside so
[Type here]
Rasmussen University
Be sure all outside sources are cited using current APA style.
Write from nursing perspective
In text citation
Three references
Used the medical diagnosis (gestational diabetes) by giving their pathophysiology, causes, risk factors, signs and symptom/clinical, complication, and treatment and fill all the concept map below
CONCEPT MAP
Pathophysiology – (to the cellular level)
Medical Diagnosis
Preterm Labor
Signs & Symptoms/Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies) (What symptoms does your client present with?)
Complications
Treatment (Medical, medications, intervention and supportive)
Causes/Risk Factors (chemical, environmental, psychological, physiological and genetic)
.
REMEMBER THAT THE EXPECTED OUTCOMES MUST BE MEASURABLE. THE INTERVENTIONS ARE WHAT YOU DO TO ASSURE THE OUTCOME AND THE CLIENT’S RESPONSE IS SPECIFICALLY HER RESPONSE.
PLAN OF CARE:Use your top two priorities
NANDA NURSING DIAGNOSIS use NANDA definition
Expected outcomes of care (Goals)
Interventions
Patient response
Goal evaluation
NRS DX:
Problem Statement:
R/T: (What is the cause of the symptom)
Manifested by: (Specific symptoms)
Short term goal: Create a SMART goal that relates to hospital stay/shift/day.
Long term goal: Create a SMART goal that is appropriate for discharge.
This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)
Interventions for short-term goal:
1.
2.
3.
Interventions for long term goal:
1.
2.
3.
Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch)
Reassess for short-term goal:
1.
2.
3.
Reassess for long-term goal:
1.
2.
3.
Was it met or not met there is no partially met.
Summer 2021 JM 9
[Type here]
Be sure all outside sources are cited using current APA style.
Write from
nursing
perspective
In text citation
Three references
Used the medical diagnosis
(gestational
diabetes)
by giving their pathophysiology, causes, risk factors, signs and
symptom/clinical, complication, and treatment
and
fill all the concept map
below
CON
CEPT MAP
Pathophysiology
–
(to the cellular level)
Medical Diagnosis
Preterm Labor
Signs &
Symptoms/
Clinical
Manifestations
(all data subjective
and objective: labs, radiology, all
diagnostic
studies) (
What symptoms
does your client present with?)
Complications
Treatment
(Medical, medications,
intervention and supportive)
Causes/
Risk Facto
rs
(chemical,
environmental, psychological, physiological
and genetic
)
[Type here]
Be sure all outside sources are cited using current APA style.
Write from nursi ...
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The document discusses best practices for documenting patient history and exams, including:
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- Asking follow up questions to the chief complaint using mnemonics like TADD, OPQRST, and OLD CARTS to fully understand symptoms.
- Documenting details of the history of present illness by addressing at least 4 of 9 symptom characteristics for comprehensive exams.
- Using "telegraphing" to shorten notes while maintaining meaning. The chief complaint should always be in the patient's own words within quotation marks.
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