SOAP Note (SOAP NOTE TEMPLATE ATTACHED BELOW)
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 that you evaluated in Unit 6 platform.
THE PLAN AND ASSESSMENT AT THE END OF SOAP NOTE MUST HAVE REREFENCES, AT LEAST THREE NOTHING LESS THAN THAT PLEASE. APA FORMAT.
HERE IS THE INFORMATION ABOUT THE UNIT 6 VIRTUAL PATIENT:
Mr. Anthony Quinn, 58 y/o male, has come to the clinic today with concerns of increased confusion.
Vital Signs
- BP 150/78
- Pulse 80
- Temp 37.1 °C
Past medical History: Hypertension
Medications: Atenolol 50 mg, Tylenol
Has family: wife and three kids
Alcohol: a beer or two occasionally on weekends
Tobacco: Does not use.
Psych: No feelings of depression or unhappiness.
Neuro Assessment: He is alert and oriented x4. Knows where he is, full name and date of birth, knows who the president is.
Urinary Assessment: “I’m not sure. Sometimes not much urine comes out, but other times it’s a normal amount.” I don’t pee as much as I used too”.
Surgical history: Vasectomy 22 years ago.
Previous Hospitalizations: None.
Allergies: no known allergies.
Family medical History: High blood pressure from my mom and diabetes from my dad runs in my family.
LABS Ordered: Albumin, 24 hour urine, basic metabolic panel, BUN/CR, CBC, CMP, renal profile, UA.
Referral to nephrologist.
Follow up with primary care physician.
Top differential diagnosis: Dementia
Lead Diagnosis: Acute Kidney Injury.
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 in a logical fashion that 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 an opportunity to demonstrate their ability to accumulate historical and examination-based information, make use of their medical knowledge, and derive a logical plan of care.
The core aspects of the SOAP note are described in detail below.
For ease of learning, a SOAP Note Template has been provided. For this assignment, proper citation and referencing is required 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 OLDCARTS, 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.
