The core aspects of the SOAP note are described in detail below.
For ease of learning, a SOAP note template has been provided. This assignment requires proper citation and referencing because this is an academic paper.
S: Subjective information. Everything the patient tells you. This includes several areas, including the chief complaint (CC), the history of present illness (HPI), medical history, surgical history, family history, social history, medications, allergies, and other information gathered from the patient. A commonly used mnemonic to explore the core elements of the history of present illness (HPI) is OLD CARTS, which includes: onset, location, duration, characteristics, aggravating factors, relieving factors, treatments, and severity.
O: Objective is what you see, hear, feel or smell. Your physical exam includes vital signs.
A: Assessment/your differentials.
P: Plan of care including health promotion and disease prevention for the patient related to their age and gender.
If there are any questions, please contact your instructor.
SOAP Note
This assignment will demonstrate your ability to provide age-appropriate anticipatory guidance while recognizing the need to refer patients that are outside of the scope of practice of the family nurse practitioner. This will be demonstrated by completing a SOAP note based on the virtual reality patient you evaluated in Unit 2.
Write-ups
The SOAP note serves several purposes:
- It is an important reference document that provides concise information about a patient’s history and exam findings at the time of patient visit.
- It outlines a plan for addressing the issues which prompted the office visit. This information should be presented logically and prominently features all of the data that’s immediately relevant to the patient’s condition.
- It is a means of communicating information to all providers who are involved in the care of a particular patient.
- It allows the NP student to demonstrate their ability to accumulate historical and examination-based information, use their medical knowledge, and derive a logical plan of care.
Knowing what to include and what to leave out will largely depend on experience and your understanding of illness and pathophysiology. If, for example, you were unaware that chest pain is commonly associated with coronary artery disease, you would be unlikely to mention other coronary risk factors when writing the history. As you gain experience, your write-ups will become increasingly focused. You can accelerate the process by actively seeking feedback about all the SOAP notes you create and reading those written by more experienced practitioners.
PLEASE FOLLOW THE SOAP NOTE AS STATED , IT HAS TO BE EXACTLY IN THIS SOAP NOTE TEMPLATE FORMAT , MAKE SURE TO FILL ALL THE REQUIRED ENTRIES ON THE SOAP NOTE , THAT NOTHING OF WHAT IT IS ASKED FOR IN THE TEMPLATE IS MISSING.
Unit 4
●Case: Veronica Chen
●Scenario Description: The patient is a 12 year old female presenting with a complaint of abdominal pain over the past few months. She thinks she noticed the stomach pain a few days after school started but admits the first time she had similar stomach pain was in the spring of last year. Associated symptoms include nausea, diarrhea, headaches and tiredness.
Your physical exam needs to match the condition that you are treating.
Miss Veronica Chen, 12 y/o female, has come into the office today with her mother Amy Chen. Veronica has complaints of abdominal pain, fatigue, and headaches. Mrs. Chen has consented to you speaking with Veronica one-on-one. [PCS spark Patient]
LET ME KNOW IF YOU NEED ACCESS TO THIS PATIENT’S LAB PROFILE ON PCS SPARK TO GIVE YOU MY LOG IN INFO.
