Description
Pease complete a SOAP Note analysis based on the following information: SOAP Note Attached, Example of an analysis attached
Rubric SOAP
Case Analysis SOAP GRADING RUBRIC with Cultural interventions
Guidelines:
1-Choose a client from your clinical setting & write up a case analysis (see below for content).
2- SOAP note from your clinical should be included (remove all patient identifiers)
SUBJECTIVE Analysis (10 POINTS) Score received
1- Compare & contrast subjective section with literature
taking into consideration the following criteria;
a-Identified and collected the necessary data including the
patients culture
b-Categorized and organized data using the appropriate format
c-Incorporated all pertinent data/facts
d- Used proper documentation
OBJECTIVE Analysis (10 POINTS) Score received
1- Compare & contrast objective section with literature taking into consideration the following criteria
a. Identified and collected the necessary data
b. Categorized and organized data using the appropriate format
c.Incorporated all pertinent data/facts
d. Used proper documentation
ASSESSMENT Analysis (35 POINTS) Score received
1- Compare & contrast subjective section with literature taking into consideration the following criteria
a-Filtered relevant data from irrelevant data
b.-Interpreted relationships/patterns among data (e.g., noted trends)
c.Integrated information to arrive at diagnosis
d.Identified risk factors
e. Differentials listed & discussed in comparison to actual diagnosis
e. Used proper documentation
PLAN Analysis (35 POINTS) Score received
1- Compare & contrast subjective section with literature taking into consideration the following criteria
a. Recommended an appropriate plan for each problem
b-Included recommendations for non-drug and drug therapy
c-Included recommendations for monitoring
d- Included health education
e- Included follow-up& referrals
f. Incorporate any cultural interventions which were done specifically for this patient
FORMAT ( 10 POINTS) Score received
1- APA
2- References Current
3- Writing clear, concise
4- Summary/Conclusion
TOTAL
** The patient’s culture must be identified and an intervention regarding the culture should be addressed in the plan.
Unformatted Attachment Preview
SOAP Note
Subjective
This patient is an 81-year-old female who presents for a follow up visit regarding recent lab
values. Lab values reflect elevated HgA1C and LDL values. Patient reports no changes in overall
health since last visit. Patient denies chest pain, shortness of breath, dizziness, or other
concerning symptoms. At this patient reports failure to comply with medication regimen,
explains she believed she did not need to take medications anymore. Patient denies smoking,
vaping, or any tobacco products. Patient denies alcohol consumption. Patient has 2 daughters and
3 granddaughters. Patient has no allergies and surgical history of an appendectomy when she was
40 years old.
Objective
Vital Signs:
Blood pressure: 130/78 mm Hg
Heart Rate: 84 bpm
Respiratory Rate: 18 breaths/min
Laboratory Results: HgA1c: 8.2%, LDL: 183mg/dL
HEENT: Pupils are equal, round, reactive and responsive to light and accomodation. No
evidence of icterus or conjunctival pallor. External ears appear symmetrical and without lesions.
The tympanic membranes are intact bilaterally. Nasal passages are patent, with no signs of
congestion or discharge. No tonsillar enlargement or exudates noted.
Appearance: The patient presents well groomed, awake, alert, and oriented with no apparent
distress. No signs of pallor, jaundice, or visible abnormalities.
Neck: No goiter, no masses, no lesions.
Chest: Clear to auscultation.
Heart: Regular rate and rhythm with S1 and S2 heart sounds present. No murmurs, rubs, or
gallops noted on auscultation.
Abdomen: Soft and non-tender on palpation. No masses, organomegaly, or guarding noted.
Extremities: No clubbing, cyanosis, or edema observed in extremities. Peripheral pulses
(femoral, popliteal, dorsalis pedis, and posterior tibial) are bilaterally equal and strong. Sensation
and motor strength are intact in all extremities.
Assessment
The patient is an 81-year-old Cuban female with a history of hyperlipidemia and Type 2 Diabetes
Mellitus. Her current BMI categorizes her as obese, which contributes to her increased risk of
cardiovascular disease. Her vital signs at the time of consultation are within normal range: heart
rate of 84 bpm, blood pressure of 130/78 mm Hg, respiratory rate of 18 breaths/min. Laboratory
values reflected an HgA1c of 8.2% and LDL of 183mg/dL. These values are consistent with the
diagnosis of hyperlipidemia and type 2 diabetes mellitus.
Plan
Discussed with patient lab value results, confirming the diagnosis of hyperlipidemia and type 2
diabetes mellitus. We discussed the complications of unmanaged high cholesterol levels and
glucose values. All complications were discussed with patient such as cardiovascular risk, nerve
damage, blindness, and kidney failure. We discussed importance of diet and physical activity.
Physical activity was recommended to aid in weight management and improve glycemic control.
Patient was instructed to maintain a heart-healthy diet low in saturated fats and refined sugars.
Patient will keep food log and will start coming to the facility for exercise three times a week.
We reviewed and emphasized the importance of medication adherence. Patient is to take
Metformin and Atorvastatin daily. We will see patient for a follow-up appointment in three
months to monitor progress and adjust treatment plan as needed.
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SOAP Note 2: Cardiology and Respiratory
Zuanlys Delgado, Melissa Fundora, Jorge Gainza, Lisette Metauten, Karina Sanchez
Nicole Weirtheim College of Nursing and Health Sciences
Florida International University
NGR 6002
May 24, 2023
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Initials of Patient: B.T
Patient Age: 47
Patient Gender: Male
Patient Race/Ethnicity: African American
Initials of provider: M.G
Clinical Setting: Glez and Glez Health Clinic
Subjective
Chief Complaint: Follow-up visit
History of Present Illness
The patient, a 47-year-old African-American male, presents for a follow-up visit after being seen
three weeks ago for an upper respiratory infection. During that visit, an incidental finding of
elevated blood pressure was noted, with a reading of 164/98 mm Hg. The patient vaguely recalls
being informed in the past that his blood pressure was “borderline.” He currently reports feeling
well, without any specific complaints, and his review of systems is negative. The patient denies
smoking cigarettes but admits to consuming a few beers on weekends and having a sedentary
job. A family history assessment reveals that his father experienced a stroke at the age of 69,
while his mother, who is 72 years old, is in good health. There are no known chronic medical
conditions among his siblings. Today, the patient’s blood pressure is measured as 156/96 mm Hg
in the left arm and 152/98 mm Hg in the right arm. His vital signs are within normal limits,
including a pulse of 78 beats/min and a respiratory rate of 14 breaths/min. Physical examination
findings are unremarkable. A clear chief complaint is not explicitly expressed during the
encounter.
Past Medical History
The patient’s past medical history reveals limited significant findings. He recalls being informed
in the past that his blood pressure was “borderline,” indicating a history of possible hypertension.
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However, there is no documentation of a formal diagnosis or treatment for hypertension.
Additionally, he had an upper respiratory infection three weeks ago, which was managed
appropriately.
Allergies: None
Chronic Medical Conditions: None
Surgical History: None
Past Hospitalizations:None
Psychiatric History: None
Family History
Mother: Age 72, alive, healthy
Father: Deceased, suffered a stroke at age 69
Sibling 1: Age 54, male, healthy
Sibling 2: Age 41, female, healthy
Grandfather: Deceased, hx of HTN and HLD.
Grandmother: Deceased, hx of HTN and DM.
Social History
Cultural Background: African American
Spiritual History/Religious Affiliation and Practices: Practicing Catholic
Complementary/Alternative Care Practices: The patient identifies with his AfricanAmerican heritage and embraces cultural care practices that have been passed down
through generations. For instance, he values traditional herbal remedies and incorporates
them into his health regimen, believing in their holistic healing properties.
Marital Status: Married in a committed relationship for 15 years.
Parental Status: Lives with two children, ages 12 and 8.
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Work History: The patient has been employed in a sedentary job as an office
administrator for the past 12 years. His work primarily involves administrative tasks,
computer work, and attending to phone calls and emails.
Financial History: The patient has maintained a stable financial status, with no
significant debt and a comfortable income that allows him to meet his financial
obligations and provide for his family’s needs.
Diet history: The patient’s diet history reveals a pattern of suboptimal dietary choices.
Due to convenience and time restrictions, he admits to eating a diet heavy in processed
meals, sugary snacks, and fast food.
Exercise: None.
Stress Management: None
Sleep: The patient claims to occasionally have trouble getting to sleep. He reports
sleeping for about 6-7 hours per night on average. He states that he wants to develop a
more reliable sleep schedule and enhance the quality of his sleep.
Social Support: Siblings, Children, Spouse, and Mother
Sexual History/orientation: The patient identifies as heterosexual and reports being in a
committed relationship with his spouse.
Travel History: None
Review of Symptoms
Constitutional: The patient denies fever, chills, or fatigue.
Head/Face: No reported injuries or specific symptoms related to the head or face.
Eyes: The patient has no vision problems, history of eye conditions, or symptoms such as
discomfort, photophobia, diplopia, spots or floaters, discharge, excessive tearing, or
itching.
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Ears: The patient does not experience hearing loss, tinnitus, or ear drainage. No history
of chronic ear infections.
Nose: No loss of sense of smell, epistaxis, obstruction, polyps, rhinorrhea, itching,
sneezing, or sinus problems reported.
Mouth/Throat/Neck: No difficulties swallowing. No evidence of gingivitis, mouth
ulcers, or bleeding gums.
Respiratory: No history of respiratory distress, dyspnea, coughing, or hemoptysis
reported.
Cardiac: No reported orthopnea, murmurs, palpitations, arrhythmias, peripheral edema,
or claudication.
G.I.: The patient denies abdominal pain, nausea, or vomiting. Normal bowel movements,
no alarming signs such as melena, hematochezia, hematemesis, hemorrhoids, or jaundice.
GU: No dysuria or blood in the urine. Normal urine stream, clear-yellow in color, with
no hesitancy or dribbling.
Musculoskeletal: No reported achy soreness or severe pain in any specific areas.
Skin/Integument: No reported rashes, bruising, itchiness, or skin lesions.
Psychiatric: No symptoms of irritability or other psychological concerns were reported.
Neuro: No neurological symptoms were reported, except for difficulty falling asleep.
Endocrine: No temperature intolerance or complaints related to hormone therapy.
Hematologic/Lymphatic: No reported swollen lymph nodes or abnormalities.
OBJECTIVE DATA
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Vital Signs:
Temp: 36.7
BP: 156/96 (L) / 152/98 (R)
Pulse: 78
Resp: 14
Oxygen Saturation: 97%
Ht: 70” / 177.8 cm
Wt: 210 lbs / 95.3 kg
BMI: 30.9
Pain: 0
Physical Examination
Constitutional: Well patient here for 3 week follow up of URI, no complaint
General: Obese, well groomed 47 y.o. African American male. A&O x3, in no acute distress,
normal affect and appropriate
Head/face: Head and scalp normocephalic, normal hair distribution
Eyes: EOM intact, red reflex visualized, PERRLA, no cataracts noted b/l, eyelids without
redness or swelling. Funduscopic examination shows no signs of hypertensive retinopathy
Ears: No tenderness on palpation of tragus, no erythema or effusion. Tympanic membrane
translucent in bilateral ears
Nose: Normal midline septum. No erythema or swelling of turbinates, no discharge
Mouth: Mucous membrane moist, no lesions. Normal dentition, no gingival inflammation
Throat: No Pharyngeal erythema and uvula midline. No ulcers noted. No foul odor from mouth,
no tonsillar enlargement or exudate
Neck: Supple and no lymphadenopathy, no nuchal rigidity and thyroid tissue firm and nontender
Respiratory: No cough, B/L BS clear in all fields, respirations are unlabored, no use of
accessory muscles
Cardiac: RRR, S1S2, no murmurs. Normal pulses in all four extremities. No edema. Cap refill
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