Description
Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.Use the Rubric listed below ,50% of the SOAP Note is completed.
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Comprehensive Women’s Health History and Physical SOAP Note
Encounter Date: 10/19/23
Preceptor/s Name:
Student Name
Faculty Name: St. Thomas University
Course Number: NUR 514CL – Advanced FNP: Clinical II – 2023 Fall 2
Patient Demographics:
Gender: Female
Race: African American
Age Range: 27 years
Ethnicity: Black
Reason for Seeking Health Care: Follow-Up- Routine. “I am having terrible menstrual cramps and heavy
bleeding.”
HPI: F.D. is a pleasant 27-year-old African-American female. Good historian, AOX 3. She
came into the clinic complaining of dysmenorrhea and heavy bleeding. The patient complains of
dysmenorrhea for a few years. The patient states the pain is a 10 out of 10 during menstruation.
The patient states she tries Tylenol Extra Strength and Midol for menstrual pain. The OTC
medication does not help alleviate the pain. Pain occurs during the menstrual cycle. It becomes
worse when the patient consumes cold beverages. Pain is currently a 0 out of 10 due to patient’s
menstrual cycle was October 8th, 2023. She is currently sexually active with only one partner, her
boyfriend. Treatment options are discussed at bedside. Labs were drawn, and the patient will be
informed of the results when available.
Allergies (Drug/Food/Latex/Environmental/Herbal): No known allergies.
Current perception of Health: Good.
Menstrual History
Age at Menarche: 12 years old
Last menstrual period: October 8th, 2023
Menstrual Pattern: Regular
1
Cycle Length: 28 days
Duration of Flow: 4- 5 days
Amount of Flow : 5 pads a day
Bleeding Pattern: Heavy
Break through Bleeding: Denies
Gynecologic History
History of breast disease, breast feeding, use of self-breast exam, last mammogram (if
applicable): Not applicable
Previous GYN surgery (may include that in surgical history) : Denies
History of infertility: Not Applicable
History of diethylstilbestrol (DES) use by patient’s mother: Not applicable
Last pap smear, history of abnormal pap: July 2023- Normal Pap Smear
Pre-menopause/menopause
Vasomotor symptoms: Not applicable
Hormone Replacement Therapy: Not applicable
Sexual and Contraceptive History
Current method of contraception: Birth control
Sexually active: Yes
Number of sexual partners: 1
New partners in the 3-6 months: 1
Condom use : No
History of sexual abuse: No
History of sexually transmitted infections (STIs): No
Obstetric History (including complications)
2
Past Medical History
• Major/Chronic Illnesses: Iron deficiency anemia
• Trauma/Injury: No falls or injury
• Hospitalizations: Bone marrow biopsy in 2021
Past Surgical History: Bone marrow Biopsy
Family History: Father: Colon cancer diagnosed at age 59. Mother: Pre-diabetic, Paternal
Grandmother- Breast Cancer at age 64. Paternal Grandfather: Prostate cancer
Medications: Junel FE (28)Take one tablet a day, Ferrex 150mg, Take one capsule by mouth
daily.
Social History:
Lives: House
Marital Status: Single
Employment Status: Employed
Current/Previous occupation type: Registered Nurse
Exposure to: Sun
Recreational Drug Use: No
Sexual orientation: Homosexual
Sexual Activity: Straight
Contraception Use: Condoms
Family Composition: Family
Health Maintenance
3
Exposures: the sun.
Immunization H.X.: Up to date.
Screening Tests (Mammogram et al., etc.): Pap Smear- Negative July 2023
Review of Systems:
General: Alert and Oriented x 3. Denies any recent fever or chills. Denies any fatigue.
HEENT: Head Normal, no mass or lesions noted.
Eyes: Pupils are round and reactive. Ears: No inflammation noted. Ears symmetrical to head.
Conjunctiva White. No changes in vision.
Nose: Septum midline. Throat: No redness noted. Trachea midline
Neck: Symmetrical. No mass or swollen lymph nodes were noted. No neck tenderness noted
Lungs: Symmetrical. No mass was noted.
Cardiovascular: S1 and S2 noted—capillary Refill less than 3 seconds. No Murmur heard
Breast: No lymph or swelling. No nipple discharge
G.I.: Active Bowel sounds. Non-tender, soft abdomen. No hernia noted
Female genital: No lesions, inflammation, discharge or tenderness noted
GU: Normal urine output and color.
Neuro: No tremors, vertigo, or dizziness were noted. Denies any weakness
Musculoskeletal: Denies joint pain or swelling. No edema noted. Full movement noted on the
Upper and lower extremities. Normal gait.
Activity & Exercise: Physically active. Workout 3 times a month
Psychosocial: No mental illness. Normal affect and mood.
Derm: Warm, dry skin. No lesion or discoloration noted. Appropriate skin color for race
4
Endocrine: Denies polyuria, polydipsia, and polyphagia. denies weight loss
Hematologic/Lymphatic: Iron deficiency anemia, History of Iron transfusion, denies history
of blood transfusions
LMP: October 8th, 2023
STI Hx: No STI reported.
Physical Exam
B.P.: 96/58 Right arm, sitting TPR: 98.4 F Oral H.R.: 70 R.R.: 17 Ht.: 5 ft 6 inch
Wt.: 69.1 kg . BMI (percentile): 23.9 Pain: 0
General: Alert and Oriented x 3. Denies any recent fever or chills. Denies any fatigue.
HEENT: Head Normal, no mass or lesions noted.
Eyes: Pupils are round and reactive. Ears: No inflammation noted. Ears symmetrical to head.
Conjunctiva White.
Nose: Septum midline. Throat: Trachea midline.
Neck: Symmetrical. No mass or swollen lymph nodes.
Pulmonary: Lungs clear bilaterally.
Cardiovascular: Normal S1 and S2 sounds. Capillary refill less than 3 seconds. No Murmur
Breast: No lymph or swelling. No nipple discharge
G.I.: Active Bowel sounds. Non-tender, soft abdomen. No hernia was noted.
Female genital: No lesions, inflammation, discharge, or tenderness noted
GU: Normal urine output and color.
Neuro: No tremors, vertigo, or dizziness were noted. Denies any weakness
5
Musculoskeletal: Denies joint pain or swelling. No edema noted. Full movement noted on the
upper and lower extremities. Normal gait.
Derm: Warm, dry skin. No lesion or discoloration was noted. Appropriate skin color for race
Endocrine: Denies polyuria, polydipsia, and polyphagia. denies weight loss
Hematologic/Lymphatic: Iron deficiency anemia, History of Iron transfusion, denies history
of blood transfusions
Significant Data/Contributing.: Glucose: 101, BUN 10, Creatinine 0.89, Sodium 143,
Potassium 3.5, Chloride 102, CO2 25, Calcium 9.6, HGB 12.1, HCT 32.6, Platelet Count 242,
WBC 3.3,
Assessment
Differential Diagnoses (3 minimum)
Primary Diagnoses
Plan (For each primary diagnosis, include laboratory/diagnostic tests, therapeutic/pharmacological
therapy, referrals, and follow-up ordered and patient education done for this visit)
Diagnoses
Laboratory/Diagnostic Studies
Therapeutic (Non-pharmacological interventions)
Pharmacological Therapy
Patient Education/Anticipatory Guidance
Referrals
Follow up
DEA#: 101010101
Tel: (000) 555-1234
STU Clinic
LIC# 10000000
FAX: (000) 555-12222
6
Patient Name: (Initials)______________________________
Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________
Refill: _________________
No Substitution
Signature: ____________________________________________________________
Signature (with appropriate credentials): __________________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
7
Distinguised
Excellent
Fair
Poor
Includes a direct quote from patient about
presenting problem
Includes a direct quote from patient and other
unrelated information
Includes information but information is NOT a
direct quote
Information is completely missing
4 Points
Begins with patient initials, age, race,
ethnicity and gender (5 demographics)
3 Points
Begins with 4 of the 5 patient demographics
(patient initials, age, race, ethnicity and gender)
2 Points
Begins with 3 or less patient demographics
(patient initials, age, race, ethnicity and gender)
Information is completely missing
2 Points
1.5 Points
1 Points
0 Points
Includes the presenting problem and the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors,
Timing and Severity)
Includes the presenting problem and 7 of the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors, Timing
and Severity)
Includes the presenting problem and 6 of the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors, Timing
and Severity)
Information is completely missing
5 Points
3 Points
2 Points
0 Points
If allergies are present, students lists only the
type of allergy name
Information is completely missing
1 Points
0 Points
Subjective
Chief Complaint (Reason for seeking
health care)
Demographics
History of the Present Illness (HPI)
Allergies
Includes NKA (including = Drug,
If allergies are present, students lists type Drug,
Environemental, Food, Herbal, and/or Latex
environemtal factor, herbal, food, latex name and
or if allergies are present (reports for each
includes severity of allergy OR description of
severity of allergy AND description of
allergy
allergy)
2 Points
Review of Systems (ROS)
1.5 Points
Includes 3 or fewer assessments for each body
Includes 3 or fewer assessments for each body
Includes a minimum of 3 assessments for
each body system and assesses at least 9 system and assesses 5-8 body systems directed to system and assesses less than 5 body systems
chief complaint AND uses the words “admits” directed to chief complaint OR student does not
body systems directed to chief complaint
use the words “admits” and “denies”
and “denies”
AND uses the words “admits” and “denies”
12 Points
6 Points
3 Points
0 Points
Information is completely missing
0 Points
Objective
Vital Signs
Includes all 8 vital signs, (BP (with patient
Includes 7 vital signs, (BP (with patient position), Includes 6 or less vital signs, (BP (with patient
position), HR, RR, temperature (with
HR, RR, temperature (with Fahrenheit or Celsius position), HR, RR, temperature (with Fahrenheit
Fahrenheit or Celsius and route of
and route of temperature collection), weight,
or Celsius and route of temperature collection), Information is completely missing
temperature collection), weight, height, BMI
height, BMI (or percentiles for pediatric
weight, height, BMI (or percentiles for pediatric
(or percentiles for pediatric population) and
population) and pain.)
population) and pain.)
pain.)
2 Points
Labs
Medications
Includes a list of the labs reviewed at the
visit, values of lab results and highlights
abnormal values OR acknowledges no
labs/diagnostic tests were reviewed.
3 Points
Includes a list of all of the patient reported
medications and the medical diagnosis for
the medication (including name, dose, route,
frequency)
1.5 Points
Includes a list of the labs reviewed at the visit,
values of lab results but does not highlight
abnormal values.
1 Points
0 Points
Includes a list of the labs reviewed at the visit but
does not include the values of lab results or
Information is completely missing
highlight abnormal values.
2 Points
1 Points
Includes a list of all of the patient reported
medications and the medical diagnosis for the
medication (including 3 of the 4: name, dose,
medications route, frequency)
Includes a list of all of the patient reported
medications (including 2 of the 4: name, dose,
route, frequency)
0 Points
Information is completely missing
Screenings
Past Medical History
4 Points
Includes an assessment of at least 5
screening tests
2 Points
Includes an assessment of at least 4 screening
tests
3 Points
2 Points
Includes (Major/Chronic, Trauma,
Includes (Major/Chronic, Trauma,
Hospitaliztions), for each medical diagnosis,
Hospitaliztions), for each medical diagnosis,
year of diagnosis and whether the diagnosis either year of diagnosis OR whether the diagnosis
is active or current
is active or current
3 Points
Past Surgical History
Family History
Social History
0 Points
Information is completely missing
1 Points
0 Points
Includes each medical diagnosis but does not
include year of diagnosis or whether the
diagnosis is active or current
Information is completely missing
1 Points
0 Points
Includes, for each surgical procedure, the
Includes, for each surgical procedure, the year of Includes, for each surgical procedure but not the
year of procedure and the indication for the
procedure OR indication of the procedure
year of procedure or indication of the procedure Information is completely missing
procedure
3 Points
Includes an assessment of at least 4 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and
cancer.
3 Points
Includes all of the following: tobacco use,
drug use, alcohol use, marital status,
employment status, current/previous
occupation, sexual orientation, sexually
active, contraceptive use, and living
situation.
3 Points
Physical Examination
2 Points
1 Points
Includes an assessment of at least 3 screening
tests
Includes a minimum of 4 assessments for
each body system and assesses at least 5
body systems directed to chief complaint
12 Points
2 Points
1 Points
0 Points
Includes an assessment of at least 3 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and cancer.
Includes an assessment of at least 2 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and cancer.
Information is completely missing
2 Points
1 Points
0 Points
Includes 10 of the 11 following: tobacco use,
Includes 9 or less of the following: tobacco use,
drug use, alcohol use, marital status, employment drug use, alcohol use, marital status, employment
status, current/previous occupation, sexual
status, current/previous occupation, sexual
Information is completely missing
orientation, sexually active, contraceptive use,
orientation, sexually active, contraceptive use,
and living situation.
and living situation.
2 Points
1 Points
0 Points
Includes a minimum of 3 assessments for each
Includes a minimum of 2 assessments for each
body system and assesses at least 4 body systems body system and assesses at least 4 body systems Information is completely missing
directed to chief complaint
directed to chief complaint
6 Points
3 Points
0 Points
Assessment
Diagnosis
Includes a clear outline of the accurate
Includes a clear outline of the accurate diagnoses
principal diagnosis AND lists the remaining
Includes an inaccurate diagnosis as the principal
addressed at the visit but does not list the
Information is completely missing
diagnoses addressed at the visit (in
diagnosis
diagnoses in descending order of priority
descending priority)
5 Points
Differential Diagnosis
3 Points
2 Points
0 Points
Includes at least 3 differential diagnoses for Includes 2 differential diagnoses for the principal Includes 1 differential diagnosis for the principal
Information is completely missing
the principal diagnosis
diagnosis
diagnosis
5 Points
3 Points
Plan
2 Points
0 Points
Pharmacologic treatment plan
Diagnostic/Lab Testing
Education
Anticipatory Guidance
Follow up plan
Includes a detailed pharmacologic treatment
Includes a detailed pharmacologic treatment plan
Includes a detailed pharmacologic treatment plan
plan for each of the diagnoses listed under
for each of the diagnoses listed under
for each of the diagnoses listed under
“assessment”. The plan includes ALL of
“assessment”. The plan includes less than 4 of
“assessment”. The plan includes 4 of the
the following: drug name, dose, route,
the following: the drug name, dose, route,
following 7: the drug name, dose, route,
frequency, duration and cost as well as education
frequency, duration and cost as well as
frequency, duration and cost as well as education
education related to pharmacologic agent. If
related to pharmacologic agent. If the diagnosis
related to pharmacologic agent. If the diagnosis is
the diagnosis is a chronic problem, student
is a chronic problem, student includes
a chronic problem, student includes instructions
includes instructions on currently prescribed
instructions on currently prescribed medications
on currently prescribed medications as above.
medications as above.
as above.
Information is completely missing
5 Points
Includes appropriate diagnostic/lab testing
100% of the time OR acknowledges “no
diagnostic testing clinically required at this
time”
5 Points
3 Points
2 Points
0 Points
Includes appropriate diagnostic/lab testing 50%
of the time OR acknowledges “no diagnostic
testing clinically required at this time”
Includes appropriate diagnostic testing less than
50% of the time.
Information is completely missing
3 Points
2 Points
0 Points
Includes at least 3 strategies to promote and
develop skills for managing their illness and
at least 3 self-management methods on how
to incorporate healthy behaviors into their
lives.
Includes at least 2 strategies to promote and
develop skills for managing their illness and at
least 2 self-management methods on how to
incorporate healthy behaviors into their lives.
Includes at least 1 strategies to promote and
develop skills for managing their illness and at
least 1 self-management methods on how to
incorporate healthy behaviors into their lives.
Information is completely missing
5 Points
3 Points
2 Points
0 Points
Includes at least 3 primary prevention
strategies (related to age/condition (i.e.
immunizations, pediatric and pre-natal
milestone anticipatory guidance)) and at
least 2 secondary prevention strategies
(related to age/condition (i.e. screening))
Includes at least 2 primary prevention strategies
(related to age/condition (i.e. immunizations,
pediatric and pre-natal milestone anticipatory
guidance)) and at least 2 secondary prevention
strategies (related to age/condition (i.e.
screening))
Includes at least 1 primary prevention strategies
(related to age/condition (i.e. immunizations,
pediatric and pre-natal milestone anticipatory
guidance)) and at least 1 secondary prevention
strategies (related to age/condition (i.e.
screening))
Information is completely missing
4 Points
Includes recommendation for follow up,
including time frame (i.e. x # of
days/weeks/months)
4 Points
2 Points
Includes recommendation for follow up, but does
not include time frame (i.e. x # of
days/weeks/months)
2 Points
1 Points
0 Points
Does not include follow up plan
0 Points
0 Points
Moderate level of APA precision
Incorrect APA style
Information is completely missing
3 Points
2 Points
1 Points
0 Points
Free of grammar and spelling errors
Writing mechanics need more precision and
attention to detail
Writing mechanics need serious attention
3 Points
2 Points
0 Points
Writing
References
Grammar
High level of APA precision
0 Points
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