The SOAP note (an acronym for Subjective, Objective, Assessment, and Plan) is a method of documentation employed by healthcare providers to write notes in a patient's chart. The SOAP note captures important clinical information about the patient encounter. Episodic SOAP notes are used when documenting a patient encounter unrelated to a specific problem or diagnosis (e.g., a new patient visit, an annual physical).
On the other hand, focused SOAP notes are used when documenting a patient encounter related to a specific problem or diagnosis. In this Episodic/Focused SOAP Note assignment, students can be asked to write an episodic SOAP note and a focused SOAP note based on different clinical scenarios. For each scenario, you will need to include the four components of a SOAP note: Subjective, Objective, Assessment, and Plan.
Use complete sentences and proper grammar when writing your episodic and focused SOAP notes. In addition, be sure to include all pertinent information about the patient encounter in each section of the SOAP note. If you are having trouble with your Episodic/Focused SOAP Note assignment, we can help you now.
Episodic/Focused SOAP Note SAMPLE
Assignment 1
Book: Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Format: Episodic/Focused SOAP Note format (sample attached)
Nausea and Vomiting
A 20-year-old female complains of nausea and has vomited three times over the past 48 hours. The patient also experienced a low-grade fever this morning. She states that she recently ate shellfish at a new restaurant with two friends who are suffering from similar symptoms.
Post a description of the health history you would need to collect from the patient in the case study. Explain which physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Assignment 2
Book:Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins.
Video: Laureate Education, Inc. (Executive Producer). (2012). Pharmacology for the gastrointestinal system. Baltimore, MD: Author.
This media presentation outlines drug treatment options for disorders of the gastrointestinal system.
Note: The approximate length of this media piece is 2 minutes.
Format: fully detail discussion paper
Patient HL comes into the clinic with the following symptoms: nausea, vomiting, and diarrhea. The patient has a history of drug abuse and possible Hepatitis C. HL is currently taking the following prescription drugs:
- Synthroid 100 mcg daily
- Nifedipine 30 mg daily
- Prednisone 10 mg daily
- Reflect on the patient’s symptoms, medical history, and drugs currently prescribed.
- Think about a possible diagnosis for the patient. Consider whether the patient has a disorder related to the gastrointestinal and hepatobiliary system or whether the symptoms are the result of a disorder from another system or other factors such as pregnancy, drugs, or a psychological disorder.
- Consider an appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed.
With these thoughts in mind: Post an explanation of your diagnosis for the patient including your rationale for the diagnosis. Then, describe an appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed.
Assignment 3
To prepare :
- Review Chapter 49 of the Arcangelo and Peterson text, as well as the Krummenacher et al. and Scourfield articles in the Learning Resources.
- Reflect on whether or not the prevalence of HIV cases might be attributed to increased complacency due to more advanced drug treatment options for HIV/AIDS.
- Consider how health care professionals can help to change perceptions and make people more aware of the realities of the disease.
- Think about strategies to educate HIV positive patients on medication adherence, as well as safe practices to reduce the risk of infecting others.
With these thoughts in mind:
By Day 3
Post an explanation of whether or not you think the prevalence of HIV cases might be attributed to increased complacency due to more advanced drug treatment options.Then, explain how health care professionals can help to change perceptions and increase awareness of the realities of the disease. Finally, describe strategies to educate HIV positive patients on medication adherence, as well as safe practices to reduce the risk of infecting others.
Episodic/Focused SOAP Note Template SAMPLE
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
A.
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
Episodic/Focused SOAP Note Template References
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.
