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 4.
INFORMATION ON UNIT 4 PATIENT.
Cindy Haas, 37, has come in with concerns about her abnormal periods.
Vital signs:
- BP: 120/70 mmHg
- P: 62 BPM
- R: 20 RPM
- T: 98°F
- BMI: 28.7
Medications she takes: Prenatal Vitamins
Previous Hospitalizations: No
Medical History: None
Family medical history: Father has high blood pressure and mother has diabetes.
Alcohol: Drinks wine 2-3 glasses per week
No tobacco nor drug consumption.
Lives in her two-story house, with her husband.
Last PAP smear was about a year ago.
No history of STD’s.
PHYSICAL EXAM:
Cardiovascular
Respiratory
GI – Palpation
GI – Auscultation
Diagnostics
Labs – CBC
Labs – CMP
Labs – Follicle Stimulating Hormone (FSH)
Labs – Lipid Panel
Labs – Prolactin
Labs – Thyroid-Stimulating Hormone (TSH)
Labs – Testosterone
Labs – Urine Pregnancy Test
Labs – Dehydroepiandrosterone sulfate (DHEA-S)
Labs – Luteinizing Hormone
Labs – Sex Hormone Binding Globulin (SHBG)
Management
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 ATTACHED BELOW 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, 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.
