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SOAP Note Assignment Wk3

SOAP Note Assignment Wk3

SOAP Note Assignment Wk3

Download and analyze the case study for this week. Create a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.

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Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.

Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.

Download the access codes.

Download the SOAP template to help you design a holistic patient care plan. Utilize the SOAP guidelines to assist you in creating your SOAP note and building your plan of care. You are expected to develop a comprehensive SOAP note based on the given assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan.  If the information is not in the provided scenario please consider it normal for SOAP note purposes, if it is abnormal please utilize what you know about the disease process and write what you would expect in the subjective and objective areas of your note. SOAP Note Assignment Wk3

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    GeniturinaryClinicalCase..pdf

    Week 4: Genitourinary Clinical Case © 2016 South University

     

     

    2 Week 4: Genitourinary Clinical Case

     

    Patient Setting: 28-year-old female presents to the clinic with a 2 day history of frequency, burning and pain upon urination; increased lower abdominal pain and vaginal discharge over the past week.

    HPI Complains of urinary symptoms similar to those of previous urinary tract infections (UTIs) which started approximately 2 days ago; also experiencing severe lower abdominal pain and noted brown fouls smelling discharge after having unprotected intercourse with her former boyfriend.

     

    PMH Recurrent UTIs (3 this year); gonorrhea X2, chlamydia X 1; Gravida IV Para III

     

    Past Surgical History Tubal ligation 2 years ago.

     

    Family/Social History Family: Single; history of multiple male sexual partners; currently lives with new boyfriend and 3 children. Social: Denies smoking, alcohol and drug use.

     

    Medication History None Allergy: Trimethoprim (TOM)/ Sulfamethoxazole (SMX) -Rash ROS Last pap 6 months ago, Denies breast discharge. Positive for Urine looking dark.

    Physical exam BP 100/80, HR 80, RR 16, T 99.7 F, Wt 120, Ht 5’ 0”

    Gen: Female in moderate distress. HEENT: WNL. Cardio: Regular rate and rhythm normal S1 and S2. Chest: WNL. Abd: soft, tender, increased suprapubic tenderness. GU: Cervical motion tenderness, adnexal tenderness, foul smelling vaginal drainage. Rectal: WNL.

     

    Page 2 of 3 Advanced Nursing Practice I

    ©2016 South University

     

     

    3 Week 4: Genitourinary Clinical Case

     

    EXT: WNL. NEURO: WNL.

     

    Laboratory and Diagnostic Testing Lkc differential: Neutraphils 68%, Bands 7%, Lymphs 13%, Monos 8%, EOS 2% UA: Starw colored. Sp gr 1.015, Ph 8.0, Protein neg, Glucose neg, Ketones neg, Bacteria – many, Lkcs 10- 15, RBC 0-1 Urine gram stain – Gram negative rods Vaginal discharge culture: Gram negative diplococci, Neisseria gonorrhoeae, sensitivities pending Positive monoclonal AB for Chlamydia, KOH preparation, Wet preparation and VDRL negative

     

    Page 3 of 3

    Advanced Nursing Practice I ©2016 South University

     

    • Patient Setting:
    • HPI
    • PMH
    • Past Surgical History
    • Family/Social History
    • Medication History
    • Physical exam
    • Laboratory and Diagnostic Testing
  • attachment

    SOAPNoteTemplate..doc

    SOAP NOTE

    Name: Date: Time:
      Age: Sex:
    SUBJECTIVE
    CC: 

    Reason given by the patient for seeking medical care “in quotes”

     
    HPI:  Use OLDCART acronym

    Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.

     
    Medications: (list with reason for med ) write medicine the same way you write a Rx

     
    PMH (list approximate year of Dx of the disease or when surgical procedure performed)

    Allergies: 

     

    Medication Intolerances:

     

    Chronic Illnesses/Major traumas

     

    Hospitalizations/Surgeries

     

     
    Family History (list immediate family, age, disease, and whether is dead or alive)

    Does your mother, father or siblings have any medical or psychiatric illnesses?  Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.

     
    Social History

    Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana.  Safety status

     
    ROS (Start each sentence with words such as “Denies, admits, complains, reports”, do not use the words “No, positive for, negative for”. Do NOT list physical exam findings here. If the body system not assess write “Non-Contributory”
    General

     

    		 Cardiovascular

     
    Skin

     

    		 Respiratory

     
    Eyes

     

    		 Gastrointestinal

     
    Ears

     

    		 Genitourinary/Gynecological

     
    Nose/Mouth/Throat

     

    		 Musculoskeletal

     
    Breast

     

    		 Neurological

     
    Heme/Lymph/Endo

     

    		 Psychiatric

     
    OBJECTIVE- this is where you document physical exam findings, do NOT use the word NORMAL to document a finding, and instead explain what normal is. For example, the gait is not normal, the gait is steady. If the body part not assessed then type “Deferred”.
    Weight        BMI Temp BP
    Height Pulse Resp
    General Appearance

     
    Skin

     
    HEENT

     
    Cardiovascular

     
    Respiratory

     
    Gastrointestinal

     
    Breast

     
    Genitourinary

     
    Musculoskeletal

     
    Neurological

     
    Psychiatric

     
    Lab Tests (lists any tests ordered and status of the test, if a rapid test was done at the office, list the results)

     
    Special Tests (List any imaging study or special test ordered and status of the test, if the result is available, write the result)

     
     Diagnosis
     Differential Diagnoses with ICD 10 codes (these are Dx you considered, but then ruled out)

    · 1-

    · 2-

    · 3-

    Diagnosis with ICD 10 Code

    CPT Code/Office visit code:

     
    Plan/Therapeutics
    · Plan:

    · Further testing

    · Medication

    · Education

    · Non-medication treatments

    · Follow Up

    · Referral

    · When to seek emergency care

     
     Evaluation of patient encounter

    Document your level of interaction with the patient.

    Weaknesses:

    Strengths:

    Reflection:

    References: