A 22-year-old female presents with a history of asthma and three days of increased wheezing and shortness of breath. She works at the local zoo during the summer to save money for the school year.
Create a SOAP Note on this patient using evidence-based content. Using the information provided on the first paragraph on this patient along with content and resources provided in this course and in NURS 620. Also use patients you have encountered in the clinical setting as a guide.
Utilize the typical clinical presentation for HPI, PMH and ROS. Include necessary components of the physical examination, diagnostic studies if appropriate, differential and actual diagnosis with treatment, follow-up, and education. Think about the pertinent negative and positive findings related to the diagnosis you are using.
Provide at least two citations at the end of the SOAP note for reference.
SOAP Note Grading Criteria
HPI, ROS, and PMH (meds/allergies, medical/surgical, and family/social): HPI: 4 or > elements identified; ROS: 4 >pertinent systems identified, with pertinent positives and negatives; PMH: >3 appropriate to history identified.
Objective assessment is complete with relevant data and diagnostic testing.
Problem Identification and Prioritization: Most problems are identified and rationally prioritized, final diagnosis is supported by subjective and objective findings.
Treatment Plan (Including dose, route & freq): Treatment plan is appropriate, complete, follows appropriate guidelines and fully addresses the identified diagnosis/problem.
Counseling, Referral, Monitoring & Follow-up: Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) is complete and clearly articulated.
SOAP Note Template
S.O.A.P. Note Template CASE ID# ____________________________
Subjective
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
Chief
Complaint What brought you here today…(eg. headache)
History of Present Illness Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form
Onset
Location
Duration
Character
Aggravating/associated factors
Relieving factors
Temporal factors – other things going on
Severity
Past Medical History Adult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current medications
Family History Include Parents, siblings; grandparents if applicable/known, cause of death, age, pertinent medical illnesses
Personal/Social History Education, marital status, occupation, alcohol/drug use, smoking status, sexual history if relevant, exercise, nutrition, religious preference if known
Review of Systems General:
Hair, Skin, & Nails:
Head:
Neck:
Eyes:
Ears:
Nose:
Mouth & Throat:
Cardiovascular:
Respiratory:
Breasts:
Gastrointestinal:
Musculoskeletal:
Peripheral:
Neurological:
Psychiatric:
Physical Examination Vital signs:
General Appearance:
HEENT:
Neck:
Lymph Nodes:
Chest:
Cardiac:
Abdomen:
Genitourinary:
Skin:
Musculoskeletal:
Neurologic:
Psychiatric:
Assessment Primary diagnosis:
Differential Diagnosis:
Plan 1.
2.
3.
