Soap note NUR7070 #1

FOCUSED SOAP NOTE GUIDE and RUBRIC The SOAP note should mimic clinical documentation in the practicum setting. The documentation should be accurate, clear, well organized, and utilized medical terminology.

SUBJECTIVE (20 points) CC – the reason for the visit as stated in the patient’s own words Example: I have been coughing frequently for 5 days. HPI (History of Present Illness) – includes symptom dimensions, chronological narrative of patients complaints.

Use PQRST or OLDCARTS mnemonic to guide you in obtaining pertinent information. If the information is obtained from other sources, always identify the source.

For example, Mr. X is a 54 yr. old man with HTN, wo presents with frequent cough X 5 days, worse at night with small amount of whitish sputum, etc. (include all pertinent negatives and pertinent positives to the chief complaint) HTN was diagnosed 5 years ago and treated with amlodipine. Reports normal BP readings and at home and at other PCPs offices last 6 months. PMH (Pertinent past medical history)

Medications – Current medications (list with daily dosages). Allergies Pertinent Family History, Social History and other subjective data if relevant to the patients presenting problem and diagnosis. ROS (Pertinent review of systems) a system- based list of questions that help uncover symptoms not otherwise mentioned by the patient. In a focused SOAP note, only include systems pertinent to the presenting problem and/or diagnosis.

OBJECTIVE (20 points) Vital signs other objective data PE focused physical exam finding limited to systems pertinent to the problem Same systems reviewed in ROS should be addressed in PE Laboratory or diagnostic data if applicable (date of these diagnostics; before this visit or during this visit).

ASSESSMENT (Problem List) with ICD-10 Codes This section documents the synthesis of subjective and objective evidence to arrive at a diagnosis. This is the assessment of the patients status through analysis of the problem, possible interaction of the problems, and changes or progress in the status of the problems. List the problem list (diagnosis/es) in order of importance. The assessment could also contain the possible causes of the patients problem, especially if the patient is experiencing an illness.

If the patient had made a visit before, it should also contain the progress which had been made since the last visit as well as the overall progress towards fully treating the symptoms, based on the perspective of the main physician.

Example: #1 acute viral bronchitis (J20.9) – Mr. X is a 54 yr. old man with HTN presents with frequent cough x 5 days, worse at night with small amount whitish sputum, denies SOB, fever and chills. Lungs clear, fremitus is equal and there is no egophony. Most likely acute viral bronchitis.

#2 HTN, controlled (I10) PLAN This has to be evidence-based using the latest clinical guidelines. This should include pharmacologic, non-pharmacologic, education, referrals, and follow-up when applicable. The plan should be personalized and appropriate for the patient.

The plan should address all the problems in Assessment.

Example: #1 acute viral bronchitis (J20.9) – supportive care, no antibiotic therapy – OTC Dextromethorphan/guaifenesin 10ml Q4hrs – Avoid decongestants due to HTN – Follow up in 1 week if no improvement or if condition worsens, a CXR can be done to r/o pneumonia.

#2 HTN, controlled – continue amlodipine 5 mg daily. – Low Na diet discussed EVIDENCE-BASED RATIONALE (20 points) –

Identify 3 differential diagnoses considered. Provide a brief rationale for each differential diagnosis (3-4 sentences) – rationale should provide data that support your differential diagnoses presentation, PE finding and/or lab/diagnostic test results that make it similar to the diagnosis and explain the difference between the differential and working diagnoses and/or the laboratory/diagnostic tests that would make the diagnosis. Cite. – Briefly discuss the rationale of the plan. Provide clinical guidelines used to support the plan, cite.