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 INFORMATION ON THE PATIENT I EVALUATED FOR UNIT 2.
Amber Renee Carter, 7, has arrived with her parents to the clinic. Her stepmother is with her during the interview. Amber was referred by Hurley Hospital ER after jumping out of her bedroom window. She presents angry and with severe impulsive behaviors.
Vital Signs
- BP 110/76
- Pulse 82
- RR: 18
- 02: 99%
- Temp 36.7 °C
- Weight: 65 lb
Does not take any medication.
Not in any pain or discomfort.
Lives with her dad and Janice (step mother).
Family history: “I’m not aware of any conditions in our family. Only Amber’s biological mother had mental issues. I know she had some kind of mental diagnosis but I’m not sure what it was.”
Diagnostic: Conners comprehensive behavior rating scale
Management referral: follow up with psych doctor
Lead diagnosis/differential diagnosis : behavioral disorder
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.
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. I ATTACHED THE SOAP NOTE TEMPLATE 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 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.
PLEASE PROVIDE REFERENCES AT LEAST 3 APA STYLE. YOU CAN PROVIDE THEM ON THE DIAGNOSIS PR EDUCATION PART. PLEASE.
