Use the attached SOAP note document to develop a soap note for the below case study,
Ms. Washington is a 67-year-old African American female who is brought to your office by her daughter with concerns of “forgetfulness.” She has lived with her daughter for 4 years now, and her daughter reports noticing she asks the same questions even after they have been answered. She even reports her mom getting lost in Walmart recently. Ms. Washington has lived with her daughter since losing her husband of 57 years, about 4 years ago. Her daughter states her mother is a retired teacher and usually very astute but notices more forgetfulness.
According to Ms. Washington’s daughter, Angela, her mom has been demonstrating increased forgetfulness of more recent things but can easily recall historical moments and events. She also reports that sometimes her mom has difficulty “finding the right words” in a conversation, and then will shift to an entirely different line of conversation. She also said her mother will “laugh off” things when she forgets important appointments and/or becomes upset or critical of others who try to point these things out.
Note: Be sure to review the Mini-Mental State Exam (MMSE) and how to interpret the results. Use the MMSE, in the attached document, to determine the patient’s MMSE score in the video. Make sure you document the patient’s score in your note document: Mental State Assessment TestLinks to an external site..
Ms. Washington is a 67-year-old female who is alert, cooperative with today’s clinical interview. Her eye contact is fair. Speech is clear and coherent but tangential at times. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She is alert and oriented to person, partially oriented to place but is disoriented to time and place. (She reported that she thought was headed to work but “wound up here,” referring to your office, at which point she begins to laugh it off.) She denies any falls or pain.
All other Review of System and Physical Exam findings are negative other than stated.
PMH: Hypertension, Hyperlipidemia, Osteoporosis
Allergies: Penicillin: rash, Lisinopril: cough
Medications:
- Amlodipine 10mg daily
- HCTZ 12.5mg daily
- Multivitamin daily
- Atorvastatin 40mg daily
- Alendronate 70mg orally once a week
Social History: As stated in Case Study
ROS: As stated in Case study
Diagnostics/Assessments done:
- CXR—no cardiopulmonary findings. WNL
- CT head—diffuse Cerebral Atrophy
- MMSE—Ms. Washington scores 18 out of 30 with primary deficits in orientation, registration, attention and calculation, and recall. The score suggests moderate dementia.
Please add your expected vital signs (BP 128/69, P72, T 97.7, R 18), and what PE you would perform. Remember – this is a virtual soap note, so use your past experiences to formulate your soap.
TIPS: review the ppt on How to Write a SOAP Note. Soap notes should be succinct, and not wordy. Just the facts. Use bullet points for the FH, PMH, SH, Immunizations, etc.
The only paragraphs needed (and these should be succinct as well ) are for the HPI, your assessment, and your plan. Remember: SOAP notes are NOT nursing notes, they should be written in a medical model of documentation.
How long should my SOAP note be? If you can document all the facts in a succinct manner, a soap note should not be any longer than 3-4 pages (including labs and diagnostics) Remember – putting your information in bullet points will make this easier as you go along and learn the process. Use 4 APA citation references to support your diagnosis.
