SOAP Note Week 3

SOAP Note Week 3

Download and analyze the case study for this week. Create a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.

Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.

Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.

Download the access codes.

Download the SOAP template to help you design a holistic patient care plan. Utilize the SOAP guidelines to assist you in creating your SOAP note and building your plan of care. You are expected to develop a comprehensive SOAP note based on the given assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan.  If the information is not in the provided scenario please consider it normal for SOAP note purposes, if it is abnormal please utilize what you know about the disease process and write what you would expect in the subjective and objective areas of your note.

SOAP NOTE

Name:	Date:	Time:
	Age:	Sex:
SUBJECTIVE
CC:  Reason given by the patient for seeking medical care “in quotes”
HPI:  Use OLDCART acronym Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
Medications: (list with reason for med ) write medicine the same way you write a Rx
PMH (list approximate year of Dx of the disease or when surgical procedure performed) Allergies:    Medication Intolerances:   Chronic Illnesses/Major traumas   Hospitalizations/Surgeries
Family History (list immediate family, age, disease, and whether is dead or alive) Does your mother, father or siblings have any medical or psychiatric illnesses?  Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.
Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana.  Safety status
ROS (Start each sentence with words such as “Denies, admits, complains, reports”, do not use the words “No, positive for, negative for”. Do NOT list physical exam findings here. If the body system not assess write “Non-Contributory”
General	Cardiovascular
Skin	Respiratory
Eyes	Gastrointestinal
Ears	Genitourinary/Gynecological
Nose/Mouth/Throat	Musculoskeletal
Breast	Neurological
Heme/Lymph/Endo	Psychiatric
OBJECTIVE- this is where you document physical exam findings, do NOT use the word NORMAL to document a finding, and instead explain what normal is. For example, the gait is not normal, the gait is steady. If the body part not assessed then type “Deferred”.
Weight        BMI	Temp	BP
Height	Pulse	Resp
General Appearance
Skin
HEENT
Cardiovascular
Respiratory
Gastrointestinal
Breast
Genitourinary
Musculoskeletal
Neurological
Psychiatric
Lab Tests (lists any tests ordered and status of the test, if a rapid test was done at the office, list the results)
Special Tests (List any imaging study or special test ordered and status of the test, if the result is available, write the result)
Diagnosis
Differential Diagnoses with ICD 10 codes (these are Dx you considered, but then ruled out) · 1- · 2- · 3- Diagnosis with ICD 10 Code CPT Code/Office visit code:
Plan/Therapeutics
· Plan: · Further testing · Medication · Education · Non-medication treatments · Follow Up · Referral · When to seek emergency care
Evaluation of patient encounter Document your level of interaction with the patient. Weaknesses: Strengths: Reflection:

References:

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