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 SOME INFORMATION ON THE UNIT 2 PATIENT:
Mr. Vernon Hawthorne, 55 years old, came in today with a complaint of a cough. Started 3 dys ago.
Complains of a sore throat.
Vital Signs
BP 132/65
Pulse 75
Temp 37.1 °C
SpO2 98%
Height: 6’1
Weight: 215 lb
Management
Orders/Treatments – Cough Suppressant
Follow Up Appointment
Health Promotion
Tobacco
Alcohol: relaxes at the end of day with a drink.
Drugs and Related Substances
Physical Exam
Ears
Nose & Sinus
Mouth & Throat
Cardiovascular
Respiratory
GI
Diagnostics:
check vital signs: Oxygen.
Review of Systems
General
Skin
Eyes
Ears
Mouth & Throat
Cardiac
Respiratory
Gastrointestinal
Musculoskeletal
Neurological
Family history:
Parenst are alive and active, no major health problems in his family.
surgical history:
no surgeries.
medication history:
no prescription meds just took nyquil when the symptoms started.
Hospitalizations: NO
Lead diagnosis: Upper respiratory Infection
Differential Diagnosis: Asthma
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.
Knowing what to include and what to leave out will be largely dependent 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 that you create, as well as by 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. For this assignment, proper citation and referencing is required because this is an academic paper.
Please use references and apply them in the text. APA style. Then provide a reference page.
TEMPLATE ATTACHED 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 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 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.
