Description
You MUST use the Case Study #1 as the base of this SOAP NOTE #1
Must use the sample template for your soap note, keep this template for when you start clinicals.
Templates used from another classes will not be accepted. Student must use the template provided in this class which must clearly contain the progress note (in the Assessment section) of the encounter with the patient ( this section is clearly mark in bold, highlighted and underlined). No passing grade will be granted if this section is not completed properly.
Follow the MRU Soap Note Rubric as a guide
Use APA format and must include minimum of 2 Scholarly Citations.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in Score must be less than 25% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 25%. Copy-paste from websites or textbooks will not be accepted or tolerated.
Please see College Handbook with reference to Academic Misconduct Statement.
Unformatted Attachment Preview
(Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C
Soap Note # ____ Main Diagnosis ______________
PATIENT INFORMATION
Name:
Age:
Gender at Birth:
Gender Identity:
Source:
Allergies:
Current Medications:
•
PMH:
Immunizations:
Preventive Care:
Surgical History:
Family History:
Social History:
Sexual Orientation:
Nutrition History:
Subjective Data:
Chief Complaint:
Symptom analysis/HPI:
The patient is …
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt
denies, or Pt states….. )
CONSTITUTIONAL:
NEUROLOGIC:
HEENT:
RESPIRATORY:
CARDIOVASCULAR:
GASTROINTESTINAL:
GENITOURINARY:
MUSCULOSKELETAL:
SKIN:
Objective Data:
VITAL SIGNS:
GENERAL APPREARANCE:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your
findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain
started 3 days ago after swimming. Pt denies discharge etc… on examination I
noted this and that etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example
provided) Include the in-text reference/s as per APA style 6th or 7th Edition.
Differential diagnosis (minimum 3)
–
–
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
•
–
•
–
Pharmacological treatment:
Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References (in APA Style)
Examples
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
(25th ed.). Print (The 5-Minute Consult Series).
Grading Rubric
Student______________________________________
This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of
patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.
1)
Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient
complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed
separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.
2)
Subjective Data (___30pts.): This is the historical part of the note. It contains the following:
a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse,
and associate manifestations.(10pts).
b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).
c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief
complaint, each should be written u in this manner.
3)
Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.
a)
b)
c)
Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).
Pertinent positives and negatives must be documented for each relevant system.
Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using
“ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).
4)
Assessment (___10pts.): Encounter paragraph and diagnoses should be clearly listed and worded appropriately
including ICD10 codes.
5)
Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological
and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into
separate numbered sections.
6)
Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the
appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with
which complaints? The assessment/diagnoses should be consistent with the subjective section and then the
assessment and plan. The management should be consistent with the assessment/ diagnoses identified.
7)
Clarity of the Write-up(___5pts.): Is it literate, organized and complete?
Comments:
Total Score: ____________
Instructor: __________________________________
Guidelines for Focused SOAP Notes
· Label each section of the SOAP note (each body part and system).
· Do not use unnecessary words or complete sentences.
· Use Standard Abbreviations
S: SUBJECTIVE DATA (information the patient/caregiver tells you).
Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis,
physician-recommended return(s) for this patient visit. The patient’s own words should be in quotes.
History of present illness (HPI): a chronological description of the development of the patient’s chief
complaint from the first symptom or from the previous encounter to the present. Include the eight
variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment,
Severity-OLDCARTS), or an update on health status since the last patient encounter.
Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries,
operations and hospitalizations allergies, age-appropriate immunization status.
Family History (FH): Update significant medical information about the patient’s family (parents, siblings,
and children). Include specific diseases related to problems identified in CC, HPI or ROS.
Social History(SH): An age-appropriate review of significant activities that may include information such
as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of
education and sexual history.
Review of Systems (ROS). There are 14 systems for review. List positive findings and pertinent negatives
in systems directly related to the systems identified in the CC and symptoms which have occurred since
last visit; (1) constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and
throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13)
hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE findings section.
0: OBJECTIVE DATA (information you observe, assessment findings, lab results).
Sufficient physical exam should be performed to evaluate areas suggested by the history and patient’s
progress since last visit. Document specific abnormal and relevant negative findings. Abnormal or
unexpected findings should be described. You should include only the information which was provided
in the case study, do not include additional data.
Record observations for the following systems if applicable to this patient encounter (there are 12
possible systems for examination): Constitutional (e.g. vita! signs, general appearance), Eyes,
ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric,
Hematological/lymphatic/immunologic/lab testing. The focused PE should only include systems for
which you have been given data.
NOTE: Cardiovascular and Respiratory systems should be assessed on every patient regardless of the
chief complaint.
Testing Results: Results of any diagnostic or lab testing ordered during that patient visit.
A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code)
List and number the possible diagnoses (problems) you have identified. These diagnoses are the
conclusions you have drawn from the subjective and objective data.
Remember: Your subjective and objective data should support your diagnoses and your therapeutic
plan.
Do not write that a diagnosis is to be “ruled out” rather state the working definitions of each differential
or primary diagnosis (es).
For each diagnoses provide a cited rationale for choosing this diagnosis. This rationale includes a one
sentence cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms,
the patients presenting signs and symptoms and the focused PE findings and tests results that support
the dx. Include the interpretation of all lab data given in the case study and explain how those results
support your chosen diagnosis.
P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include an EBP
citation.
1. Medications write out the prescription including dispensing information and provide EBP to support
ordering each medication. Be sure to include both prescription and OTC medications.
2. Additional diagnostic tests include EBP citations to support ordering additional tests
3. Education this is part of the chart and should be brief, this is not a patient education sheet and needs
to have a reference.
4. Referrals include citations to support a referral
5. Follow up. Patient follow-up should be specified with time or circumstances of return. You must
provide a reference for your decision on when to follow up.
Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition
AIDS (Acquired Immunodeficiency Syndrome)
Case Studies
The patient, a 30-year-old homosexual man, complained of unexplained weight loss, chronic
diarrhea, and respiratory congestion during the past 6 months. Physical examination revealed
right-sided pneumonitis. The following studies were performed:
Studies
Complete blood cell count (CBC), p. 156
Hemoglobin (Hgb), p. 251
Hematocrit (Hct), p. 248
Chest x-ray, p. 956
Bronchoscopy, p. 526
Lung biopsy, p. 688
Stool culture, p. 797
Acquired immunodeficiency syndrome
(AIDS) serology, p. 265
p24 antigen
Enzyme-linked immunosorbent assay
(ELISA)
Western blot
Lymphocyte immunophenotyping, p. 274
Total CD4
CD4%
CD4/CD8 ratio
Human immune deficiency virus (HIV)
viral load, p. 265
Results
12 g/dL (normal: 14–18 g/dL)
36% (normal: 42%–52%)
Right-sided consolidation affecting the posterior
lower lung
No tumor seen
Pneumocystis jiroveci pneumonia (PCP)
Cryptosporidium muris
Positive
Positive
Positive
280 (normal: 600–1500 cells/L)
18% (normal: 60%–75%)
0.58 (normal: >1.0)
75,000 copies/mL
Diagnostic Analysis
The detection of Pneumocystis jiroveci pneumonia (PCP) supports the diagnosis of AIDS. PCP is
an opportunistic infection occurring only in immunocompromised patients and is the most
common infection in persons with AIDS. The patient’s diarrhea was caused by Cryptosporidium
muris, an enteric pathogen, which occurs frequently with AIDS and can be identified on a stool
culture. The AIDS serology tests made the diagnoses. His viral load is significant, and his
prognosis is poor.
The patient was hospitalized for a short time for treatment of PCP. Several months after he was
discharged, he developed Kaposi sarcoma. He developed psychoneurologic problems eventually
and died 18 months after the AIDS diagnosis.
Copyright © 2018 by Elsevier Inc. All rights reserved.
Case Studies
2
Critical Thinking Questions
1. What is the relationship between levels of CD4 lymphocytes and the likelihood of
clinical complications from AIDS?
2. Why does the United States Public Health Service recommend monitoring CD4
counts every 3–6 months in patients infected with HIV?
3. This is patient seems to be unaware of his diagnosis of HIV/AIDS. How would you
approach to your patient to inform about his diagnosis?
4. Is this a reportable disease in Florida? If yes. What is your responsibility as a
provider?
.
Copyright © 2018 by Elsevier Inc. All rights reserved.
Critical Thinking Questions
Oksana Shopsha
Miami Regional University
MSN5600 L- Laboratory for Diagnosis, Symptom and Illness Management
Professor Patricio Bidart
9/23/2023
2
Critical Thinking Questions
AIDS (acquired immunodeficiency syndrome)
1. What is the relationship between levels of CD4 lymphocytes and the likelihood of clinical
complications from AIDS?
CD4 lymphocytes, or T-helper cells, are critical to the immune system. In the context of
HIV infection, the virus primarily targets and infects CD4 cells, leading to their depletion. As the
CD4 count declines, the immune system becomes increasingly compromised, and the likelihood
of clinical complications and opportunistic infections, such as Pneumocystis jiroveci pneumonia
(PCP) and Kaposi sarcoma, increases. A lower CD4 count generally indicates a more advanced
stage of HIV infection and a higher risk of AIDS-related complications (Holland et al., 2019).
2. Why does the United States Public Health Service recommend monitoring CD4 counts
every 3–6 months in patients infected with HIV?
CD4 counts provide information about a patient’s immune system status and disease
progression. They help healthcare providers make treatment decisions, such as when to initiate
antiretroviral therapy (ART) or prophylaxis against opportunistic infections. Frequent monitoring
of the CD4 cells allows for early detection of declining CD4 counts, which can prompt timely
intervention and prevent complications. Changes in CD4 counts also help assess the
effectiveness of HIV treatment and inform adjustments to the treatment regimen (Holland et al.,
2019).
3. This is patient seems to be unaware of his diagnosis of HIV/AIDS. How would you
approach to your patient to inform about his diagnosis?
3
The first step is creating a private and suitable environment for making communication.
Then, develop trust with the patient. Be empathetic with the patient and use clear language to
provide the information. Offer emotional support to the patient and allow the patient to ask any
questions (Holland et al., 2019).
4. Is this a reportable disease in Florida? If yes. What is your responsibility as a provider?
Yes, HIV/AIDS is a reportable disease in Florida, as it is in most states in the United
States. Healthcare providers have a legal and ethical responsibility to report cases of HIV/AIDS
to the appropriate public health authorities (Caruso & Swift, 2023). Reporting helps track the
spread of the disease, implement preventive measures, and allocate resources for care and
support.
Iron-Deficiency Anemia Case Study
1. What was the cause of this patient’s iron-deficiency anemia?
The patient’s first cause of iron deficiency anemia is chronic gastrointestinal (GI) bleeding, as
indicated by the positive stool occult blood test and the subsequent discovery of right-sided colon
cancer during a colonoscopy (Cotter et al., 2020). Colon cancer is responsible for the occult
blood in the stool and the gradual depletion of iron stores, leading to iron deficiency anemia.
2. Explain the relationship between anemia and angina.
Anemia can lead to angina (chest pain) due to its impact on oxygen delivery to the heart
muscle. According to Padda et al. (2021), when a person has anemia, fewer red blood cells are
available to carry oxygen to the body’s tissues, including the heart. This reduces oxygen supply
to the heart muscle, especially during physical activity when the heart’s demand for oxygen
4
increases. This makes the patient experience chest pain (angina) during exertion because the
heart cannot meet its increased oxygen demand. The pain typically ceases when the activity
stops, and the heart’s oxygen demand decreases.
3. Would your recommend B12 and Folic Acid to this patient? Explain your
rationale for the answer
I recommend vitamin B12 and folic acid supplementation to this patient, even though the
primary cause of his anemia is iron deficiency related to colon cancer and chronic GI bleeding.
The patient’s vitamin B12 level (140 pg/mL) is below the normal range, indicating a deficiency
(Cotter et al., 2020). Vitamin B12 and folic acid supplementation are commonly administered to
patients with anemia because these vitamins are essential for producing red blood cells.
4. What other questions would you ask to this patient, and what would be your
rationale for them?
The additional questions that I would ask the patient include:
•
Detailed medical history, including any history of gastrointestinal symptoms such as
blood in the stool, changes in bowel habits, or unintentional weight loss, to further assess
the GI issues.
•
Family history of colon cancer or other relevant diseases.
•
Any other symptoms or changes in health that the patient may have noticed could provide
additional diagnostic clues.
•
Medications and supplements the patient is currently taking, as certain medications can
contribute to anemia or interact with treatments.
5
•
Any history of alcohol consumption, such as excessive alcohol intake, can affect both
iron absorption and the GI tract.
•
Given the transfusion incompatibility reaction, any known allergies or sensitivities to
medications or blood products.
6
References
Caruso, J. R., & Swift, C. J. (2023). Florida HIV Safety for Florida Clinical Laboratory
Personnel. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK589667/
Cotter, J., Baldaia, C., Ferreira, M., Macedo, G., & Pedroto, I. (2020). Diagnosis and treatment
of iron-deficiency anemia in gastrointestinal bleeding: A systematic review. World
Journal of Gastroenterology, 26(45), 7242–7257.
https://doi.org/10.3748/wjg.v26.i45.7242
Holland, G. N., Van Natta, M. L., Goldenberg, D. T., Ritts Jr, R., Danis, R. P., & Jabs, D. A.
(2019). Relationship Between Opacity of Cytomegalovirus Retinitis Lesion Borders and
Severity of Immunodeficiency Among People With AIDS. Investigative Opthalmology &
Visual Science, 60(6), 1853. https://doi.org/10.1167/iovs.18-26517
Padda, J., Khalid, K., Hitawala, G., Batra, N., Pokhriyal, S., Mohan, A., Cooper, A. C., & JeanCharles, G. (2021). Acute Anemia and Myocardial Infarction. Cureus, 13(8), e17096.
https://doi.org/10.7759/cureus.17096
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