Immersion soap note

I need a soap note for a focus visit

 

Female, initials, TM, white, Caucasian, age 29 years.

Comes to clinic alone, with chief complaints : congestion, headache, runny nose x3 days, tylenols helps, nothing helps,  no recent infections, 

-works in a hospital as a nurse , does not uses a mask, has been taking tylenol 650 every 8hrs for headache. 

Lmp : x2 weeks ago, sexually active, uses protection

Exersices: finess class 3 times a week

sleeps 7 hrs a night, no  changes in sleep or night sweats. 

up to date with childhood vaccines, flu and covid 

No known associates sick, no recent illness.

Social: drinks occasionally 

Cardio:  (you can make normal findings) 

Pulmonary: normal. ( you make normal findings)

No smoking or vape use

KNA to foods or drugs, seasonal 

No medical hx: 

Family history : lung ca, sleep apnea, 

Surgery: tonsillectomy at age 12

No GI symptoms, no recent weight loss/gain, 

No ear ache, some 

Skin : intact, elastic, warm to touch, pulses equal bilaterally, no edema, no sweeping or body aches, no notable lymph nodes, 

Pertinent labs: covid negative, strep troat, negative, influenza negative

Objective findings: temp 98.3, HR 93, resp 18,  02 sat 97%, weight 180 pounds, 5.6, BMI 29.

Nose image: clear drainage, erythema noted, 

Mouth ispection: pink, no drainage, (you can make normal findings)

Ear image: fluid bubbles on ears, no pain (no urgency) 

 

I need to use ICD data .com for diferential diagnosis

 

 Diferential diagones: 

Seasonal allergies, vs, ryhitis, vs allergic sinusitis,

 

*I choose to  diagnose the pt with: Allergic Sinusitis*

 

Plan: recomend: Flonase, Zyrtec, Advil and Tylenol Alternatively.  Proper hydration and rest

Educate pt: Return to clinic if s/s worse, sob, fever , or …( make any recomendations…

 

 

 

Below a template the university uses for this, use for reference: 

I never written a SOAP and it’s worth 25% of my grade. Please help!  Use proper Medicare terminology, do not use WNL. 

I will compensate.  Thanks 

 

 

ID:

●     Client’s Initials*:_______Age_____  DOB: _____________

●     Race/ Ethnicity: __________ Gender____________

●     Arrived to the clinic accompanied or alone? ________   Who is the historian?_______

 

Subjective

CC:

●     Patient’s own words, a few words, a sentence or less. Use Quotes!

Example: “cough and fever”

 

HPI:

●     In paragraph format, including at the minimum OLDCARTS. Onset, Location, Duration, Characteristics/context, Aggravating factors or Associated symptoms,  Relieving Factors, Treatment, and Timing, Severity. Include any pertinent positives or negatives.

 

Please start with demographics: Ex: __(initials), a __ y.o. ___(race) ___(sex) presents to the clinic ____(alone or accompanied) for _____________.

 

Past Medical History:

●     Medical problem list (including the year diagnosed)

●     Preventative care: (ONLY if applicable to the case – Paps, mammography, colonoscopy, dates of last visits, etc.)

●     Surgeries/ Hospitalizations:

●     LMP (as pertinent for females)

 

Allergies:

●     Food, drug, environmental – Ask and document ALL 3 and any reaction type!

 

Medications:

●     include names, doses, frequency, and routes, and reason in parenthesis if off-label or secondary use

 

Family History:

●     As pertinent to the CC, you would review potential inherited conditions related to the body system for the case.

●     Always include if alive/ deceased, age if known, and the conditions relevant

●     First and second generation history and any other related family members if pertinent

 

Social History:

●     Sexual history and contraception/protection (as applies to the case)

●     Chemical history (tobacco/alcohol/drugs) (ask every pt about tobacco use)

●     Other social history only as applicable to each case. Exercise your critical thinking here – what is pertinent and necessary for safe and holistic care

o     Diet and Exercise

o     Spirituality/ Health Practices

o     School/work

o     Living arrangements

o     Peds: developmental history, birth history, breastfeeding,

o     Gero: ADLs, advanced directives, etc.

 

ROS: (write out by system): Only include systems pertinent to the chief complaint.

Do not include ALL 14 below. Remember to use “Patient reports and/or Patient denies” when discussing the symptoms you asked/ would ask for each system.

Remember, this is NOT your assessment so you will only document what the patient tells you!

 

●     Constitutional: Example: Patient denies any recent fever, chills, fatigue. She does report recent weight change of 10 lbs in 3 months without trying.

Other potential systems include:

●     Eyes, 

●     Ears/Nose/Mouth/Throat (ENT),

●     Cardiovascular (CV),

●     Respiratory,

●     Gastrointestinal (GI),

●     GU,

●     MSK,

●     Integumentary & breast,

●     Neurological,

●     Psychiatric,

●     Endocrine,

●     Hematologic/Lymphatic,

●     Allergic/Immunologic

Objective

 

Vital Signs:   

HR: ________          BP: _________      Temp: ______ F        RR: ___ /min     SpO2: ______% on RA      

Pain: __/10  Height: ___________ Weight: ________lb or kg     BMI _______________   

 

Labs, radiology or other pertinent studies: be sure to include the date of labs – might be POC tests from today

 

Physical Exam (write out by system):

●     General Survey/ Constitutional:

o     Ex: Pt appears comfortable and in no distress. Sitting in chair

●     CV:

●     Resp:

●       Continue to document any Pertinent body systems:

 

Assessment

 

Differential Diagnoses

●     1. Diagnosis #1 (ICD-10 Code)

o   Rationale: You might discuss the symptoms of the condition and then compare how the history and exam findings either align with this or are not consistent with it and how this helped you rule in or rule out the diagnosis (Include the in-text citation to the scholarly source or clinical practice guideline in your rationale)

●     2. Diagnosis #2 (ICD-10 Code)

o   Rationale: Same as above

●     3. Diagnosis #3 (ICD-10 Code)

o   Rationale: Same as above

 

Primary Diagnosis: Be sure you identify which of these 3 is your primary Diagnosis ________ and (ICD-10)

                     

Plan

(For the Primary Diagnosis only)

You must support each element of the plan with clinical based evidence from scholarly sources. Scholarly sources include finding the Clinical Practice Guideline (CPG) for the primary diagnosis and using this to help you defend your plan and workup for the patient below. Refer back to Immersion PPT and recording on how to find these or look in Nursing Caring Corner for Quick links. You need to use in-text citations crediting your source of information.

●     Diagnostics:

o     (Are there any labs or test needed to help you make the diagnosis or to treat/ manage; Don’t forget your rationale for the lab + in-text citations for these to support your plan for the workup)

●     Treatments:

o     (If prescription, give ALL info needed – Double check the rubric but you need the medication name, dose, route, frequency, # to dispense, and any refills)

●     Education:

o     (Educate the pt about the dx and plan – Be specific! You are the NP now with legal documentation. Supportive care options need to be specific and based on evidence!

o     Use the guidelines to also help you on educating your patient related to the diagnosis or any new medications being recommended even OTC – You need to include dose and frequency on those too)

●     Follow Up:

o     (When should they come back to see you in the clinic? When do you escalate care to the ER – Give the pt those precautions for signs and symptoms)

 

 

 

References

 

This is 25% percent of my grade please help me. I will compensate you.