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Select a patient that you examined during the last three weeks. With this patient in mind, address the following in a SOAP Note:
  • Subjective: What details did the patient provide regarding her personal and medical history?
  • Objective: What observations did you make during the physical assessment?
  • Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
  • Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
  • Reflection notes: What would you do differently in a similar patient evaluation?

Patient Information:

Chief Complaint

vaginal discharge and odor
 
History of Present Illness
21 yo presents with c/o vaginal discharge. she did have positive chlamydia  on 1/5/17 and states that she and her partner were treated. She denies having intercourse since that time.. she has not had a TOC. describes discharge as being light and being present for 1 week. There is an odor but it is not a fishy odor.. She also wants to know if she is able to use represh products to prevent vaginal discharge. She denies any abdominal pain, fever
 
Review of Systems
Constitutional: Denies fevers chills
 Gastrointestinal: Denies nausea vomiting diarrhea, abdominal pain
 Genitourinary: Negative
 Gynecological: see HPI
 Neurologic: Negative
 Psychiatric: Denies anxiety and depression
 
Physical Exam
Vitals & Measurements
HR: 77 (Peripheral)  BP: 116/71
HT: 64.5 in  WT: 175.8 lb  BMI: 29.71
  
 Gen.: Alert and oriented, not acute distress
 Abdominal: Nontender nondistended, bowel sounds present, incisions clean dry and intact
 Genitourinary:
 Vagina: Scant white discharge in the posterior fornix
 Cervix: Cervical mucus and Mirena IUD strings noted at the os
 Neurologic: Alert and oriented
 
Assessment/Plan
 
1. Acute Chlamydia trachomatis infection of genitourinary site
 GCC obtained. encouraged condoms consistently. no signs of PID.
 
****pt contacted and informed of positive Chlamydia results. pt informed that medication has been sent her pharmacy. pt informed that she was given 500mg dosage so this time she will take two pills PO at the same time. pt informed that her partner can go to the health department for treatment. pt informed that the third party needs to be treated as well. pt educated on the importance of all parties being treated to reduced exposure and reinfection. pt verbalized understanding, no further questions at this time.
99214 office outpatient visit 25 minutes (Charge), Quantity: 1, Acute Chlamydia trachomatis infection of genitourinary site | Vaginal discharge
 
2. Vaginal discharge
 Affirm collected. treat per results.

 

 

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, or fever

Skin: rashes, lumps, sores, itching, dryness, changes, etc.

HEENT:

Neck:

Breasts:

Respiratory:

Cardiovascular:

Gastrointestinal:

Peripheral vascular:

Urinary:

Genital:

Musculoskeletal:

Psychiatric:

Neurological:

Hematologic:

Endocrine:

Total points for objective date -15.

OBJECTIVE DATA: This is what you see, hear, feel when doing your physical exam. Again, you go head to toe and you only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see. Only list systems related to diagnosis. If you did a physical exam you must have that system listed in the ROS>

Here is where the vital signs go. Include ht and wt and BMI value 1 point

For pediatric please include height, weight and bp percentile value 1 points

This section value 12 points except 1 point for Respiratory and Cardiac

General: General state of health, posture, motor activity and gait. Dress, grooming, hygiene. Odors of body or breath. Facial expression, manner, affect and reactions to people and things. Level of conscience.

SKIN:

HEENT:

Neck:

Chest/Lungs: ALWAYS INCLUDE IN YOUR PE value 1 point

Heart/Peripheral Vascular: ALWAYS INCLUDE THE HEART IN YOUR PE value 1 point

Abdomen:

Genital:

Musculoskeletal:

Neurological:

ASSESSMENT section value @ 30 points. Hint List the priority diagnosis in bold and it should be the first diagnosis (2 points), the positive findings from the patient of that diagnosis (2 points) ,the negatives of that diagnosis from your patient (2 points), rationale (3 points) reference used (1 pt). Please include the same for the differentials. The above is an example of how the points are broken down for this section but depends on how many diagnosis patient has.

ASSESSMENT: Need to list your priority diagnosis(es) first and in bold. For each priority diagnosis, list 2 differential diagnoses. Support your selection with evidence.

Diagnosis

Positives

Negatives

Rationale & Reference

Iron deficiency Anemia

low h/h, low iron, high tibc, low mcv

– none

Type supporting evidence from textbook, journal etc

Anemia of chronic disease

low h/h, low iron, low mcv

high tibc

Pernicious Anemia

low h/h

low iron, low mcv, high tibc

Lab/Imaging (Results)

Patient results

Rationale & Reference

For holistic care you need to include previous diagnoses and indicate whether these are controlled or not controlled and remember to include that in your treatment plan. Example

Holistic Care

Chronic Condition

Status

Plan

Diabetes

Controlled

Continue current medication

Lab/Imaging (Results)

Patient results

Rationale & Reference

PLAN: Value 15 points- APA format please for works sited. General guideline for assignment of points: 1 pt. for non pharmacological, 4 pts. for meds, 4 points for test/diagnostics, 2 pts. for f/u, 2 pts. for health promotion, 2 pts. for disease prevention

PLAN: Treatment plan. Labs, x-rays, etc. Include both pharmacological and nonpharmacological strategies. Include alternative therapies. When do they need to follow-up? Any referrals? Consultations?

Condition

Pharmacological

Nonpharmacological &

Alternative Treatments

Test

Follow up &

Referral

Rationale & Reference

Health Promotion: What does the patient/ family need to do to promote their health? Exercise, healthy diet, safety, etc. You must go to the USPTF site for Adults, Bright Futures for Kids. This is not related to the diagnosis this is based on patient age and gender.

Disease Prevention: For the patient’s age, what needs to be done to detect disease early…fasting lipid profile, mammography, colonoscopy, immunizations, etc Use the UPSTF guideline for Adults or for Pediatrics Bright Futures. The website will show you the specifics based on patients age and gender.

REFLECTION section is worth 25 points

REFLECTION: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence? Really think about what you are doing in clinical. REFLECTION section is worth 25 points with following general guideline for points: 5 pts experience description, 5 pts agree/disagree with preceptor, 5 pts. Include how plan would be different for the uninsured vs insured patient, 5 pts for community resources, 5 pts for creating at least one state approved RX using the Walmart $4 plan. Your sentence introduction should be clear that you are referring to the above items.

PRESCRIPTION: Create a prescription per your state guidelines

Someone’s Clinic 123 Somewhere Lane, Tx 78233 Telephone # 123-4567 Joyce Turner APRN, FNP-BC Dr. Supervising Lic 12345 NPI 112344 Lic 2345 NPI 123444 Patient: SA DOB: 1/1/00 RX: Lisinopril 10 mg 1 po b.i.d. #60 , zero refills Signature: ___________________________

THIS IS NOT SPECIFIC THIS IS TO GIVE YOU A GENERAL GUIDELINE FOR GRADING METHOD

VW 5-13-12

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