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. HERE IS THE INFORMATION on the patient from Unit 2.
Ms. Vivian M. Lopez, 24, has come to the office today to establish care. Patient is healthy, no current health complaints or signs of illness.
Vital Signs
- BP 132/64
- Pulse 70
- Temp 37.1 °C
- Weight: 108lb
Vivian Lopez is wanting a refill on her birth control. Sexual orientation is she is gay. Only has sexual intercourse with women. No history of trauma or abuse. She has not gotten the HPV vaccine. Last pap smear: 7 years ago Her menstrual cycle (period) is heavy and painful. She drinks alcohol and smokes cannabis. She used to be on birth control but stopped taking it in university. She took birth control in high school to regulate her period.
Diagnostics: Order a pop smear. STI labs.
Management: follow up, and health promotion.
Family medical history: Both parents and siblings are healthy.
PLEASE PROVIDE REFERENCES, 3 OR MORE NOTHING LESS. PROVIDE THEM ON THE DIFFRENTIAL DIAGNOSIS AND PATIENT EDUCATION.
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 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.
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 it is an academic paper. SOAP NOTE TEMPLATE WILL BE ATTACHED IN A FILE BELOW.
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, including 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.
