Write a SOAP note from a patient who
comes to the medical office (primary physician) and is diagnosticated with moderate persistent asthma, uncompensated.
You can be guided by the guidelines and the added rubrics below and for SOAP
Note example.
This case can be based in an 18
adolescent male patient with medical history of moderate persistent asthma who
comes to the clinic complaining of shortness of breath, patient appear to be in
asthma crisis for the last 2 days. You must create a case of your own
imagination like a real one that goes to consultation with the primary doctor.
Guidelines for SOAP Notes
General Guidelines:
• Label each section of the SOAP note
(each body part and system).
• Do not use unnecessary words or
complete sentences.
• Use Standard Abbreviations
• All Heading and Subheadings must be
bolded and separate, no narrative ROS or Physical
(Paragraph Form)
All Soap Notes must include:
• Full name of student
• Date of encounter
• Name of Preceptor and Clinical
Instructor
• Title with Soap # and Main Diagnosis (Hypertension)
S: SUBJECTIVE DATA (information the
patient/caregiver tells you).
Identifying Information: The opening list
of the note. It contains age, sex, race, marital status, etc. The
patient complaint should be given in
quotes.
Chief Complaint (CC): a statement
describing the patient’s symptoms, problems, condition, diagnosis,
physician-recommended return(s) for this
patient visit. The patient’s own words should be in “quotes”. If the patient
has more than one complaint, each complaint should be listed separately (1, 2,
etc.) and each addressed in the subjective and under the appropriate number.
History of present illness (HPI): a
chronological description of the development of the patient’s chief
complaint from the first symptom or from
the previous encounter to the present. Include the eight
variables (Onset, Location, Duration,
Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS),
or an update on health status since the last patient encounter.
Past Medical History (PMH): Update
current medications, allergies, prior illnesses and injuries,
operations and hospitalizations
allergies, age-appropriate immunization status.
Family History (FH): Update significant
medical information about the patient’s family (parents, siblings, and
children). Include specific diseases related to problems identified in CC, HPI
or ROS.
Social History(SH): An age-appropriate
review of significant activities that may include information such as marital
status, living arrangements, occupation, history of use of drugs, alcohol or
tobacco, extent of education and sexual history.
Review of Systems (ROS). There are 14
systems for review. List positive findings and pertinent negatives in systems
directly related to the systems identified in the CC and symptoms which have
occurred since last visit;
(1) constitutional symptoms (e.g., fever,
weight loss),
(2) eyes, (3) ears, nose, mouth and throat,
(4) cardiovascular,
(5) respiratory,
(6) gastrointestinal,
(7) genitourinary,
(8) musculoskeletal,
(9}. integument (skin and/or breast),
(10) neurological,
(11) psychiatric,
(12) endocrine,
(13)hematological/lymphatic,
{14) allergic/immunologic. The ROS should
mirror the PE findings section.
All Sections must be included in all soap
notes
0: OBJECTIVE DATA (information you
observe, assessment findings, lab results).
Sufficient physical exam should be
performed to evaluate areas suggested by the history and patient’s progress
since last visit. Document specific abnormal and relevant negative findings.
Abnormal or unexpected findings should be described
Record observations for the following
systems for each patient encounter (there are 12 possible
systems for examination):
Constitutional (e.g. vital signs, general
appearance), Eyes, ENT/mouth,
Cardiovascular, Respiratory, GI, GU,
Musculoskeletal, Skin, Neurological, Psychiatric,
Hematological/lymphatic/immunologic/lab
testing.
Testing Results: Results of any
diagnostic or lab testing ordered during that patient visit.
A: ASSESSMENT: (this is your diagnosis
(es) with the appropriate ICD 10 code)
List and number the possible diagnoses
(problems) you have identified. These diagnoses are the
conclusions you have drawn from the
subjective and objective data.
There must be one main Diagnosis
Remember: Your subjective and objective
data should support your diagnoses and therapeutic plan.
Do not write that a diagnosis is to be
“ruled out” rather state the working definitions of each differential
or primary diagnosis (es).
For the main diagnoses provide a cited
rationale for choosing this diagnosis. This rationale includes a
one sentence cited definition of the
diagnosis (es) the pathophysiology, the common signs and
symptoms, the patients presenting signs
and symptoms and the findings and tests results that support the dx. Include
the interpretation of all lab data given in the case study and explain how
those results support your chosen diagnosis.
Must include a Minimum of 3 differential
diagnosis with ICD codes
P: PLAN (this is your treatment plan
specific to this patient). Each step of your plan must include an EBP citation.
(in-text citation)
1. Medications write out the prescription
including dispensing information and provide EBP to support ordering each
medication. Be sure to include both prescription and OTC medications.
2. Additional diagnostic tests include
EBP citations to support ordering additional tests
3. Education this is part of the chart
and should be brief, this is not a patient education sheet and needs to have a
reference.
4. Referrals include citations to support
a referral
5. Follow up. Patient follow-up should be
specified with time or circumstances of return. You must
provide a reference for your decision on
when to follow up.
6. References: Notes must have Minimum of
2 Scholarly References (Journals, Books, and Studies)
Last Completed Projects
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