Description
Ms. Jones is a 67-year-old female who is brought to your office today by her daughter Susan. Ms. Jones lives with her daughter and can perform all activities of daily living (ADLs) independently. Her daughter reports that her mother’s heart rate has been quite elevated, and she has been coughing a lot over the last 2 days. Ms. Jones has a 30-pack per-year history of smoking cigarettes but quit smoking 3 years ago. Other known history include chronic obstructive pulmonary disease (COPD), hypertension, vitamin D deficiency, and hyperlipidemia. She also reports some complaints of intermittent pain/cramping in her bilateral lower extremities when walking and must stop walking at times for the pain to subside. She also reports some pain to the left side of her back, and some pain with aspiration.
Ms. Jones reports she has been coughing a lot lately, and notices some thick, brown-tinged sputum. She states she has COPD and has been using her albuterol inhaler more than usual. She says it helps her “get the cold up.” Her legs feel tired but denies any worsening shortness of breath. She admits that she has some weakness and fatigue but is still able to carry out her daily routine.
Vital Signs: 99.2, 126/78, 96, RR 22
Labs: Complete Metabolic Panel and CBC done and were within normal limits
CMP Component
Value
CBC Component
Value
Glucose, Serum
86 mg/dL
White blood cell count
5.0 x 10E3/uL
BUN
17 mg/dL
RBC
4.71 x10E6/uL
Creatinine, Serum
0.63 mg/dL
Hemoglobin
10.9 g/dL
EGFR
120 mL/min
Hematocrit
36.4%
Sodium, Serum
141 mmol/L
Mean Corpuscular Volume
79 fL
Potassium, Serum
4.0 mmol/L
Mean Corpus HgB
28.9 pg
Chloride, Serum
100 mmol/L
Mean Corpus HgB Conc
32.5 g/dL
Carbon Dioxide
26 mmol/L
RBC Distribution Width
12.3%
Calcium
8.7 mg/dL
Platelet Count
178 x 10E3/uL
Protein, Total, Serum
6.0 g/dL
Albumin
4.8 g/dL
Globulin
2.4 g/dL
Bilirubin
1.0 mg/dL
AST
17 IU/L
ALT
15 IU/L
Allergies: Penicillin: hives
Current Medications:
Atorvastatin 40mg p.o. daily
Multivitamin 1 tablet daily
Losartan 50mg p.o. daily
ProAir HFA 90mcg 2 puffs q4–6 hrs. prn
Caltrate 600mg+ D3 1 tablet daily
Diagnosis: Pneumonia
Directions: Answer the following 10 questions directly on this template. put in bold or a different color
Question 1: What findings would you expect to be reported or seen on her chest x-ray results, given the diagnosis of pneumonia?
Question 2: Define further what type of pneumonia Ms. Jones has, HAP (hospital-acquired pneumonia) or CAP (community-acquired pneumonia). What are the differences/criteria?
Question 3:
3A) What assessment tool should be used to determine the severity of pneumonia and treatment options?
3B) Based on Ms. Jones’ subjective and objective findings, apply that tool and elaborate on each clinical factor for this patient.
Question 4: Ms. Jones was diagnosed with left lower lobe pneumonia. What would your treatment be for her based on her diagnosis, case scenario, and evidence-based guidelines?
Question 5: Ms. Jones has a known history of COPD. What is the gold standard for measuring airflow limitation?
Question 6: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having to rest to stop the leg pain/cramps. Which choice below would be the best choice for a potential diagnosis for this? Explain your reasoning.
DVT (Deep Vein Thrombosis)
Intermittent Claudication
Cellulitis
Electrolyte Imbalance
Question 7: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having to rest to stop the leg pain. What test could be ordered to further evaluate this?
Question 8: Name three (3) differentials for Ms. Jones’ initial presentation.
Question 9: What patient education would you give Ms. Jones and her daughter? What would be your follow-up instructions?
Question 10: Would amoxicillin/clavulanate plus a macrolide have been an option to treat Ms. Jones’ Pneumonia? Explain why or why not.
Support your research answers with 5 APA citations.
Unformatted Attachment Preview
Focused SOAP Note Template
*Remove descriptors before you write your note and submit.
Patient Information:
Initials, Age, Sex, Race
S (subjective)
CC (chief complaint): a BRIEF statement identifying why the patient is here, stated in the
patient’s own words (for instance “headache,” NOT “bad headache for 3 days”).
HPI (history of present illness): This is the symptom analysis section of your note. Thorough
documentation in this section is essential for patient care, coding, and billing analysis. Paint a
picture of what is wrong with the patient. Use LOCATES or OLDCARTS Mnemonic to complete
your HPI. (Most NPs use OLDCARTS, but this can be your choice)
You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must
include the seven attributes of each principal symptom in paragraph form not a list. If the CC
was “headache,” the LOCATES for the HPI might look like the following example: (can also use
OLDCARTS)
•
Location: Head
•
Onset: 3 days ago
•
Character: Pounding, pressure around the eyes and temples
•
Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia
•
Timing: After being on the computer all day at work
•
Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely
better
•
Severity: 7/10 pain scale
IMPORTANT: Do not use the HPI as a catch all for other ROS, SH, FH, PE, diagnostic studies, etc.
There are specific areas for those. Keep the HPI specific to the history of the present illness
(HPI).
Current Medications: Include dosage, frequency, length of time used, and reason for use; also
include over the counter (OTC) or homeopathic products. Put in bullet points, not paragraph
form. Other people need to read this, and time is of the essence.
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Example:
•
Flomax (tamsulosin) 0.8 mg twice a day for BPH, prescribed 2 years ago (age 78)
•
Tylenol 325 mg every 4-6 hrs. prn arthritis pain, self-prescribed 5 years ago (age 75)
Allergies: Include medication, food, and environmental allergies separately, including a
description of what the allergy is (i.e., angioedema, anaphylaxis, etc.). This will help determine a
true reaction versus intolerance. Do not put Allergies twice in the soap note.
PMH past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.
Immunization status (note date of last tetanus for all adults), do NOT write ‘up to date’
Soc and Substance Hx: Include occupation and major hobbies, family status, tobacco and
alcohol use (previous and current use), and any other pertinent data. Always add some health
promo question here, such as whether they use seat belts all the time or whether they have
working smoke detectors in the house, living environment, text/cell phone use while driving,
and support system. This should only be about a paragraph of bullet points. This is not a
discussion, only facts.
Fam Hx: Illnesses with possible genetic predisposition, contagious, or chronic illnesses. Reason
for death of any deceased first-degree relatives should be included. Include parents,
grandparents, siblings, and children. (please do not use “died of old age” unless this is what the
pt said but consider not using it. Blood relatives only.
Write succinctly: (again, bullet points)
•
M deceased age 79 MI
•
F- age 80 alive & well
Surgical Hx: Prior surgical procedures with approximate year or age. Exact date not necessary.
•
TAH age 45
Mental Hx: Diagnosis and treatment. Current concerns (anxiety and/or depression). History of
self-harm practices and/or suicidal or homicidal ideation. (if depression is suspected: screen
with PHQ-9 or GDS and document results/ and refer) or treat
Violence Hx: Concern or issues about safety (personal, home, community, sexual (current and
historical).
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Reproductive Hx: (not necessary in a focused note if the focus is not reproductive)
•
Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no),
contraceptive use (method used), types of intercourse (oral, anal, vaginal, other, any
sexual concerns).
ROS (review of symptoms): Cover all body systems that may help you include or rule out a
differential diagnosis You should list each system as follows: i.e. if a pt is being evaluated for a
stroke: do not defer the M/S, CV, or neuro ROS and PE
•
General:
•
Head:
•
EENT (eyes, ears, nose, and throat): Etc.:
Note: You should list these in bullet format and document the systems in order from head
to toe. See ppt. If already stated in the HPI: write “see HPI” No need to repeat.
Example of Complete ROS: “REVIEW OF SYMPTOMS” actually ‘Review of Systems’ – this is
where students get the most points off
*Use these examples to tailor YOUR SOAP note related to your pt/case CC, HPI, etc
Because the ROS is your interview with your patient – do not use “NO” for any ROS findings
unless you are certain it is a SYMPTOM. To be safe – just use “denies, no c/o, reports, endorses,
states” etc. It has to sound like your patient is telling you this information.
Points are taken off for each incorrect ROS statement.
i.e. when stating “no nodes” or “no anemia” in the ROS – this is points off because it sounds like
you did a PE exam (incorrect for a ROS) or you looked at labs for anemia (incorrect for ROS)
Note: I highly recommend resources, your text, apps, which give examples of ROS, and ddx
(differential diagnoses) – these will come in very handy not just to write these soap notes – but
when you are in your clinical practicum.
•
GENERAL: denies weight loss or states weight loss of __lbs over xx time (this is very
important in older adults), fever, chills, weakness, or fatigue. (if you put “no weight
loss” you are saying you weighed the pt, which belongs in the PE, not the ROS (points
off for this mistake)
•
HEENT:
Eyes: denies visual loss, blurred vision, double vision or yellow sclerae.
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Ears, Nose, Throat denies hearing loss, sneezing, congestion, runny nose, or sore throat.
•
SKIN: denies rash or itching, or c/o itching (area).
•
CARDIOVASCULAR/CV: denies chest pain, chest pressure or chest discomfort. denies
palpitations or edema. Or c/o palpitations with activity.
•
RESPIRATORY: denies shortness of breath, cough or sputum.
•
GASTROINTESTINAL: denies anorexia, nausea, vomiting or diarrhea. denies abdominal
pain or BPR (bleeding per rectum).
•
GENITOURINARY: States burning on urination. Last menstrual period (LMP),
MM/DD/YYYY. Denies hematuria, nocturia
•
NEUROLOGICAL: denies headache, dizziness, syncope, paralysis, ataxia, numbness or
tingling in the extremities. denies change in bowel or bladder control.
•
MUSCULOSKELETAL: denies muscle, back pain, joint pain or stiffness.
•
HEMATOLOGIC: denies anemia, bleeding or bruising.
•
LYMPHATICS: denies enlarged nodes. denies history of splenectomy.
•
PSYCHIATRIC: denies history of depression or anxiety, denies suicidal ideations
•
ENDOCRINOLOGIC: denies reports of sweating, cold or heat intolerance. denies polyuria
or polydipsia. C/O heat flushes since menopause
•
REPRODUCTIVE: Not pregnant and denies recent pregnancy. denies reports of vaginal or
penile discharge. Not sexually active.
•
ALLERGIES: denies history of asthma, hives, eczema or rhinitis.
*If the ROS indicates any positive symptoms, these need to be addressed in your CC,
HPI, assessment and plan. Do not just sweep them under the rug!
O (objective) DO NOT PUT SX IN THE PE
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your
physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and
History. NOTE: YOUR ROS AND PE MUST MATCH. What systems you note in the ROS must
also be noted in the PE.
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Do not use “WNL” or “normal.” You must describe what you see. Always document in headto-toe format – and proximal to distal (i.e., General: Head: EENT: etc.).
•
Vital Signs/VS: always begin PE with VS. Note the T, BP, P, Ht, Wt, BMI, and status of
the BMI (normal, overweight, obese etc) Do not repeat the VS you have already
documented, DO NOT sprinkle VS around in your note: I do take points off if you repeat
the VS any other place but in the VS section. (Unless there is something seriously wrong
with the VS then you would address it in your Plan: ie uncontrolled HTN).
•
GENERAL: note if pt is alert, oriented, and to what. DO NOT state A&Ox4 – points will be
taken off for this. State what they are oriented/or not oriented to.
•
Note their general appearance
•
HEENT: examination of eyes, ears, nose, and throat. Do not put ‘normal’ or red.
Document an actual physical exam, use your texts or Bates book for the PE write up.
•
SKIN: examination of visual skin areas: redness, rash, etc? and document the LOCATION
you examined. (unless you did a whole-body exam) i.e. ‘skin normal’ is not acceptable
•
CARDIOVASCULAR/CV: exam of heart with stethoscope: always first note the S1 S2,
rate (regular or irregular?) presence or absence of extra heart sounds (S3, S4) murmur?
Grade the murmur if you hear one. (You cannot determine cardiomyopathy with a
stethoscope), however, you can document symptoms (SOB, ankle edema, etc)
Palpitations are a sx, not a PE finding. If it’s a PE – then it is an irregular HR
Note any edema or lack of and grade it.
CV (as all PE) are head to toe, proximal to distal, so pedal edema is last in the CV exam.
(Do not begin your CV exam with pedal edema)
•
RESPIRATORY: Lung sounds. Clear or other. Percussion of chest if warranted. Common
error: DO NOT put sx here. Only write what you examine.
•
GASTROINTESTINAL: exam of the Abd. If CC is GI, do a Murphey’s or other sign. This is
one time you can document a sx i.e. “tenderness on palpation” and identify the area.
Unless the CC is GI in nature, you do not need to put the last BM.
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•
GENITOURINARY: this can be deferred unless the CC is GU in nature, then examine the
bladder and kidneys. Recommend adding the GU exam when there is Abd pain, as it can
be referred pain. Better to explore, don’t leave it out.
•
NEUROLOGICAL: this is important. You can write “CN II-XII grossly intact” which means
you are doing a visual examination of the pt, talking to them, looking at them & they
appear normal. If a more thorough neuro exam is needed (i.e. stroke or neuro CC) see
the neuro check list & do a stroke evaluation (NIH stroke scale, etc). A Romberg can go
here.
•
MUSCULOSKELETAL: always grade the muscles on each side. See the form I sent or
your PE book. Do not put “weak” or “unsteady” Name the type of gait. (See the gait
form).
•
HEMATOLOGIC: Exam any areas of bleeding, GI, GU, etc or note absence of & name the
areas you examined
•
LYMPHATICS: check nodes for swelling: NAME THE AREA you checked. Neck, groin??
Points off for this is the reader has to guess where you examined.
•
PSYCHIATRIC: Affect (mood appears depressed, normal, pleasant affect, etc).
•
ENDOCRINOLOGIC: examine the thyroid for nodes, enlargement. The endocrine exam
includes reviewing the pulse, heart rate, BP, and looking at the hair, skin, mouth, and
teeth (which you have already done) – so note any suspicions here
•
REPRODUCTIVE: can be deferred unless there is a CC
Diagnostic results heading: Do not sprinkle labs, tests, diagnostics throughout
your SOAP note. They belong in one section where other providers can find
them titled “Diagnostics”
Include any labs, x-rays, or other diagnostics that are needed to develop the differential
diagnoses (support with evidenced based guidelines).
A (assessment)
Differential diagnoses: List a three differential diagnoses. Your primary diagnosis should be at
the top of the list & will be the first one of the three.
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For each diagnosis, provide supportive documentation with evidence-based guidelines.
In-text citations and current (5 years or less) references are required.
1. Primary dx: explain why you chose this. One paragraph of evidenced-based citations of
why this primary dx. Fits your pts case, ROS, PE, etc.
2. Ddx 1: give a brief explanation of why this is not your primary dx. (Why did you rule it
out?)
3. Ddx 2: give a brief explanation of why this was also ruled out as the primary dx.
Note: Keep in mind that a pt may have more than one dx. If a pt has a PMH of HTN, put that
on the list. If they are already on medications, no need to change anything or add a
medication unless needed.
P (plan)
Includes documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, disposition of the patient, and any
planned follow up visits. Each diagnosis or condition documented in the assessment should be
addressed in the plan. The details of the plan should follow an orderly manner.
NOTE: This is a SOAP note, and not a discussion board. Your rationale for each ddx and dx,
should be succinct but thorough, it should explain your thought process in forming your final
primary dx. This should not be more than a paragraph.
Excessively long writings that do not fit the format of a soap will not have significant points
taken off. I recommend reviewing soap notes from colleagues or online when possible.
I realize many of you will be using EHR, however, all med students, residents, and APPs learn
how to write SOAP notes. This is your foundation.
Education: A succinct discussion related to health promotion and disease prevention taking
into consideration patient factors (such as, age, ethnic group, etc.), PMH, and other risk factors
(e.g., socio-economic, cultural background, etc.). is required, and something you will do as a
APRN with every patient.
Reflection: (see rubric)
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Also included in this section is the reflection which is a requirement of the SOAP note. Reflect
on this case, and discuss what you learned, including any “aha” moments or connections you
made. (This is noted in your SOAP note rubric).
This is required and points are deducted if missing. This does not need to be long but needs to
be present. .
References
You are required to include at least three evidence-based peer-reviewed journal articles or
evidenced-based guidelines, which relate to this case to support your diagnostics and
differential diagnoses.
Be sure to use correct APA 7th edition formatting.
References should be preferable U.S. based, 5 years or more recent. The reason for this is that
other countries may have different standards or medications. It is ok to use systematic review
articles from large organizations i.e. The Endocrine society, or AAN, American Academy of
Neurology.
Note: pediatric articles are not permitted for gero patients, it is ok to use Up to Date or
Medscape but not all the time. Be sure articles are peer reviewed and no older than 5 years. (I
do check these).
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