MN552 Soap Note Paper

MN552 Advanced Health Assessment

Unit 3 SOAP Note Section II and III Written Guide

1. Document appropriate data in the relevant body system.

a. Do not state “Negative, NA or Unremarkable” for any systems because the reader will not know which questions were actually asked by the provider.

2. This is a comprehensive health history and should not contain physical exam findings. The focused history data is relevant to the chief complaint and identified by pertinent positive data documented during the health history. MN552 Soap Note Paper

3. Address each component of the SOAP note as noted in the written guide with relevant data.

4. You may continue with the same volunteer to complete each section of the SOAP note.

II. Life style patterns

0. Immigrant status

0. Spiritual resources/religion

0. Health perception

0. Nutritional patterns: Appetite (any changes); satisfaction with current weight; gains or losses; recall of usual intake; any cultural restrictions/intolerances; amount of fluid per day and type

0. Elimination patterns: Bowel (usual pattern and characteristics); bladder (usual pattern and characteristics); any incontinence

0. Living environment: City, state; urban, rural, community; type of dwelling, facilities; known exposures to environmental toxins

0. Occupational health: Known exposure to environmental toxins at work

0. Functional assessment: ADLs, IADLs, interpersonal relationships/resources (see page 57 in Jarvis textbook)

0. Role and family relationships: Immediate family composition; how are family decisions made; impact of family member’s health on family

0. Cognitive function: Memory; speech; judgment; senses

0. Rest/sleep patterns: Number of hours; naps; number of pillows; any aids for sleep

0. Exercise patterns: Type and frequency

0. Hobbies/recreation: Leisure activities; any travel outside of the US

0. Social habits: Tobacco; alcohol; street drug use

0. Intimate partner violence (review screening questions on page 58 in the Jarvis textbook)

0. Coping/stress management: Any major life change in past 2 years; do you feel tense; source; what helps

0. Sexual patterns: Are you sexually active; gender preference; has anything changed about your sexual health/function

 

III. Review of Symptoms

 

	Symptoms to Inquire About (please see page 54–56 in Jarvis textbook)	Document pertinent negatives and/or positives The first system is addressed to provide a guide
General	Wgt Δ; weakness; fatigue; fevers	Pertinent negatives: No weight gain or losses; no weaknesses, fatigue, or fevers Pertinent positives: Positive weight gain over past 2 months with fatigue and weakness; no fevers
Skin	Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails
Head	Headache; head injury; dizziness or vertigo
Eyes	Vision Δ; eye pain, redness or swelling, corrective lenses; last eye exam; excessive tearing; double vision; blurred vision; scotoma
Ears	Hearing Δ; tinnitus; earaches; infections; discharge, hearing loss, hearing aid use
Nose/ Sinuses	Colds; congestion; nasal obstruction, discharge; itching; hay fever or allergies; nosebleeds; change in sense of smell; sinus pain
Throat/ Mouth	Bleeding gums; mouth pain, tooth ache, lesions in mouth or tongue, dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse; tonsillectomy; altered taste
Neck	Lumps; enlarged or tender nodes, swollen glands; goiter; pain; neck stiffness; limitation of motion
Breasts	Lumps; pain; discomfort; nipple discharge, rash, surgeries, history of breast disease; performs self-breast exams and how often, last mammogram; any tenderness, lumps, swelling, or rash of axilla area
Pulmonary	Cough — productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains; any H/O lung disease; toxin or pollution exposure; last Chest x-ray, TB skin test
Cardiac	Chest pain or discomfort; palpitations; dyspnea; orthopnea; edema, cyanosis, nocturia; H/O murmurs, hypertension, anemia, or CAD
G/I	Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance
GU	Frequency; nocturia; urgency; dysuria; hematuria; incontinence Females: Use of kegal exercises after childbirth; use of birth control methods; HIV exposure; Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP; vaginal discharge; itching; sores; lumps; menopause; hot flashes; post-menopausal bleeding; Males: Caliber of urinary stream; hesitancy; dribbling; hernia, sexual habits, interest, function, satisfaction; discharge from or sores on penis; HIV exposure; testicular pain/masses; testicular exam and how often
Peripheral Vascular	Claudication; coldness, tingling, and numbness; leg cramps; varicose veins; H/O blood clots, discoloration of hands, ulcers
Musculo-skeletal	Muscle or joint pain or cramps; joint stiffness; H/O arthritis or Gout; limitation of movement; H/O disk disease
Neuro	Syncope; seizures; weakness; paralysis; stroke, numbness/tingling; tremors or tics; involuntary movements; coordination problems; memory disorder or mood change; H/O mental disorders or hallucinations
Heme	Hx of anemia; easy bruising or bleeding; blood transfusions or reactions; lymph node swelling; exposure to toxic agents or radiation
Endo	Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe size; H/O diabetes, thyroid disease; hormone replacement; abnormal hair distribution
Psych	Nervousness/anxiety; depression; memory changes; suicide attempts; H/O mental illnesses

SOAP Note

Instructions: Enter total points possible in cell C14, under the rubric. Next enter scores (between 0 and 4) into yellow cells only in column F.
Unit 3 – SOAP Note Section 2 Grading Rubric
	Unacceptable	Below Average	Average	Above Average	Score	Weight	Final Score	Comments
	0	2	3	4
Lifestyle Patterns	No lifestyle patterns addressed.	Lifestyle patterns poorly addressed	Lifestyle patterns addressed but more detail is needed or content inconclusive.	Lifestyle patterns specific, clear and thoroughly addressed.	0	40%	0.00
Review of Systems (ROS)	No ROS addressed.	ROS poorly addressed.	ROS addressed but more detail is needed or content inconclusive.	ROS specific, clear and thoroughly addressed.	0	40%	0.00
Organized and well written	No paper submitted.	Paper was unorganized and poorly written.	Paper was somewhat organized and overall writing left room for improvement.	Paper was thoroughly organized and well written.	0	5%	0.00
Ideas stated clearly and logically	No paper submitted.	Ideas were not stated clearly or logically.	Some ideas were stated clearly and logically.	All ideas were stated clearly and logically.	0	5%	0.00
Relevance of Content	No paper submitted.	Paper was off topic and not relevant.	Some portions of paper were on topic and relevant.	Paper was thoroughly on topic and relevant.	0	5%	0.00
Spelling and grammatical errors	No paper submitted.	No formatting guidelines	Less than 6 spelling or grammatical errors.	All formatting guidelines were followed; No spelling or grammatical errors.		5%	0.00
						100%	0.00
					Final Score		0
					Percentage		0.00%
Total available points =		20	4
Rubric Score		Grade points		Percentage
Low	High	Low	High	Low	High
3.5	4.0	18	20	90%	100%
2.5	3.49	16	18	80%	89.99%
1.7	2.49	14	16	70%	79.99%
1.0	1.69	12	14	60%	69.99%
0.0	1.00	0	12	0	59.99%

MN552 Advanced Health Assessment

Unit 2 SOAP Note Section I Written Guide

 

History, Interview, and Genogram Guide

 

Date of History/Interview: 23rd, September, 2017

Source of history and Reliability: (client)

1. Biographical Data

a. Name (use initials only): Mrs. W.W.

b. Address: George street, House no. 4, California

c. Phone number 305-555-5555

d. Primary language: speaks English

e. Authorized representative: her daughter

f. Age and Date of Birth: 50 y/o, July 15, 1967

g. Place of Birth: San Diego, California

h. Gender: female

i. Race: black

j. Marital Status: divorced

k. Ethnic/Cultural Origin: African

l. Education: master’s in criminology

m. Occupation/Professional: lecturer

n. Health insurance: full medical coverage

 

2. Chief Complaint (reason for seeking health care):

a. Brief spontaneous statement in client’s own words

“The cough started as a chest cough but it has not been better since my first time visit to the clinic. During the day it doesn’t bother me as much, but during the night I cough a lot. For the last few weeks I have experienced pain in the chest.” MN552 Soap Note Paper

b. Includes when the problem started

“I started coughing like three months ago. I have undergone treatment from regular hospitals but nothing seems to change.”

3. History of Present Illness: A well organized, chronological record of client’s reason for seeking care, from time of onset to present. Please include the 8 critical characteristics using the PQRSTU pneumonic.

P – Provocative or palliative

The client states that in most cases room temperature affects her cough, when she feels cold she coughs more. She is also affected by strong smells like perfumes, and states that she cannot sit directly under a fan or air conditioner because the strong wind promotes her cough.

Q – Quality or quantity

The client feels pain in her chest when she coughs. Her throat is also sore. The cough produces sputum that seems clear.

R – Region or radiation

She only has coughing problem. No other complains.

S – Severity

The severity according to the patient is at 6 out of 10.

T – Timing

She states that when she starts coughing it can last for more than five minutes without stopping. She coughs mostly during the night or when she is irritated by a disturbing smell during the day or even strong wind.

U – Understand Patient’s Perception of the problem

Her fever seems low grade at 100 degrees without chills. After a long conversation with the client she says that she is worried she might have pneumonia. She has not had shortness of breath, she also denies postnasal drip. She has undergone chest X-rays, TB test, and taken many over the counter drugs and home remedies, with no improvement. MN552 Soap Note Paper

 

4. Past Medical History

a. Medical Hx: major illnesses during life span, injuries, hospitalizations, transfusions, and disabilities.

No other major medical complications, she was diagnosed with diabetes at age 45, present concern is only her cough. hospitalized once for vaginal delivery, no other surgical hx.

b. Childhood Illnesses: Measles, chickenpox, Mumps, strep throat

c. Surgical Hx; dates, outpatient, X-rays.

Vaginal delivery on 02/26/1987, Chest X ray 08/15/2017

d. Obstetric HX:

Only one pregnancy, and one delivery, she gave birth to her daughter who is the only child.no miscarriages or abortion cases.

e. Immunizations: only as a child, immunization like MMR, Varicella, Tetanus, has not received busters as adult, but last visit to the doctor they gave her the flu shot. Patient states that she does not like getting vaccines.

f. Psychiatric Hx: no psychiatric conditions reported.

g. Allergies: allergic to dust

h. Current Medications: Metformin 500mg BID for diabetes type 2.

i. Last Examination Date: 12th March, 2017

No eye problem

No foot problem

There are some cavities

No hearing problem

EKG; normal

Chest X-Ray; diffuse wheezes are present bilaterally with expiration. No crackles or bronchi.

Pap test; no cervical cancer

Mammogram; no signs of breast cancer

Serum cholesterol; cholesterol level is at 200

Stool occult blood; no colon cancer

Prostate; not relevant

PSA; not relevant

UA; not collected

TB skin test; not detected

Sickle- cell; no sickle cell disease

PKU; non-applicable

Hamatocrit; 35% – normal

 

 

Genogram Three Generation

Section 2

This section has a family medical history as stated by the patient. Patient states that she is currently divorced from her husband whose whereabouts are unknown, prior to divorce he was in good health. Patient W.W. had one daughter with her ex-husband, she is alive and has history of asthma. Patient narrates that her mother is alive and heathy for her age, her father is deceased, he had a history of heart failure. Her maternal grandmother is alive and overall healthy, just debilitated due to her age, her maternal grandfather had a heart attack and is deceased. Patients grandmother is alive with arthritis, and her paternal grandfather is alive with diabetes. On the Ex-husband family side, she knows in his family in his mother’s side his mother is alive and with diabetes, his father alive and with hypertension, his grandmother had a stroke and is deceased, and his grandfather had committed suicide. On her Ex-husbands fathers side his grandmother alive with diabetes and HTN and his grandfather is alive with prostate issues and diagnosed with BPH. MN552 Soap Note Paper