Documentation of SOAP Format SAMPLE

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Documentation of SOAP Format SAMPLE

Documentation of SOAP Format SAMPLE

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SOAP:

S-Subjective. Information from the patient/family including chief complaint, history of present illness, past medical history, past surgical history, medications, allergies, reproductive history, family history, social history, nutritional assessment, and the review of systems (ROS).

 

O-Objective. Includes anything obtained by the examiner with the eyes, ears, and hands. This is the physical examination.  It may also include lab and diagnosis results yielding immediate results (e.g. blood glucose check, Vital signs, etc)

Documentation of SOAP Format SAMPLE

Differential Diagnosis. This is not usually documented, but is part of the critical thinking process all NPs. This is where you determine the top possible causes of the symptom/chief complaint. For your paper, use references to support how you ruled in or out a given diagnosis.

 

A-Assessment. This is the final assessment (diagnosis), putting all the findings from subjective and objective together to form an appropriate diagnosis (or diagnoses). Often, evaluation/management codes (a 5 digit number called a “visit” code) and diagnosis codes (e.g. 477.81) are included in this section.

Documentation of SOAP Format SAMPLE

P- Plan. Management of the patient may include diagnostic testing that may be done at that visit or in the future, referral to another provider, plans for follow up, patient education, and any pharmacological or nonpharmacological treatment.

Example of SOAP Note-Comprehensive visit

 

Name: Date of visit: Time seen:
DOB: Sex:

 

S: History (CC, HPI, PMH/PSH, Family History, Social History, Current Health Maintenance)

 

CC – “One sentence in quotes using patient voice.”

Documentation of SOAP Format SAMPLE

HPI – Elaborate on CC using OLDCARTS or other to describe 9 attributes of a symptom. In the case of established dx’s, state when dx’d, treatment, recent relevant lab work, last medication monitoring, recent side effects or complaints related to the problems under treatment.

PMH

Immunizations –

Medications

Allergies –  drug or food or other allergies with reaction

SH-Alchol, reacreational drugs, tobacco

Hospitalizations/Surgeries or traumatic injuries

FH

Current Health Maintenance (or Personal and Social Hx)- Living environment, including others lived with;  occupation/ school

Screenings & Self-Care –

Diet

Exercise

Sleep

Other Health Care Providers

Immunizations

Habits/Substance Use

Safety

Documentation of SOAP Format SAMPLE

ROS (includes recent/current symptoms; do not include screening tests, diagnoses)

General –

Skin/Breasts –

Eyes –

Ears –

Nose/Mouth/Throat –

Neck-

Lymphatic-

Cardiovascular –

Respiratory –

Gastrointestinal –

Genitourinary:

Neurological –

Psychological:

O: Physical Examination (VS, Exam, Rapid Diagnostics if applicable)

 

Weight –          Height –               BMI-      VS:         Temp,                   B/P,       P,            R-

 

General –

Skin/Breasts –

Eyes –

Ears –

Nose/Mouth/Throat –

Neck-

Lymphatic-

Cardiovascular –

Respiratory –

Gastrointestinal –

Genitourinary:

Neurological –

Psychological:

A: (Diagnoses, including E/M visit codes and diagnosis codes)

Differential Diagnosis (give a rationale for each diagnosis and cite a reference)

Final Assessment/Diagnosis:

 

P: (Plan): Documentation of SOAP Format SAMPLE

SOAP NOTE

Name: Maggie Smith (MS)     Date: _____2/18/2019_____  Time: __0800_________

Age: 19 yo                                           Sex: F

SUBJECTIVE:

CC– The patient states that, “I just have real bad pain in my lower stomach.”

HPI: MS, complains of having severe pain in her lower abdomen lasting for 2 days. The pain, however, does not radiate to the back or her legs. She states that she doesn’t think it was brought about because of something that she ate and she has no difficulty eating.” She describes the pain as sharp and deep and makes her noxious. She states that she has vomited twice ever since the pain started but denies blood in the emesis. She states that she has had a temperature of 102oF. The pain is worse when she stands up, walks or lies down and is relieves when she is curls into a ball. She has been taking Tylenol to manage the pain without relief. She states the pain has been constant and sharp for 2 days and rates it a 10/10.

  • Onset – 2 days ago
  • Location- lower abdomen
  • Duration – 2 days
  • Character – sharp, deep, and nauseating
  • Aggravating factors – standing up, walking or lying down
  • Alleviating factors – curling up
  • Radiation – does not radiate to the back or her legs. Just the lower abdomen.
  • Timing – the pain has been constant for the 2 days.
  • Severity – 10/10 on the pain scale

PMH:  Painful periods, unmanaged for the past 2 months.

PSH: Denies ever having any surgery.          

Medications:

OTC – Tylenol 500mg PO PRN pain

Ortho-Cyclen (28) PO Q Daily – but she has not taken past 2 months.

Allergies: NKDA.

FMH:

Mother: Alive, age 45, with a history of hypertention and hypercholesterolemia. Hysterectomy for ovarian cancer.

Father: Alive, age 45, with a history of type II DM

Sister: Alive and healthy

Brother: Alive, has bipolar disorder.

Maternal grandparents:

Grandmother died at age 60 from breast cancer

Grandfather, alive, age 65, hypertention and hypercholesterolemia

Does not know the medical history of paternal grandparents.

SH: Sexually active, with one partner in a serious relationship and uses condoms occasionally. Denies any history of smoking or using any illicit drugs. Drinks a few glasses of alcohol occasionally, once a week. Student and active church member. No new hobbies or new diet.

ROS: 

General: Denies unintentional weight gain, weight loss, or dizziness. Denies any problems with night sweats.

Skin: Denies any itching, dry skin or lesions.

Eyes: Denies dryness or blurred vision.

Ears: Denies any ear pain or discharge. Can hear without aides.

NoseMouthThroat: Denies cough, sore throat or rhinitis.

Neck: denies stiffness or pain in the neck.

Cardiovascular: Denies any history of heart problems, chest pain, palpitations or edema.

Respiratory: Denies any shortness of breath or wheezing.

Gastrointestinal: Reports sharp constant pain in the lower abdomen. Pain on palpation of the lower abdomen with rebound tenderness. Denies constipation or diarrhea.

Genitourinary: Denies any pain upon urination. Denies urine discoloration. Reports presence of a normal clear thin white vaginal discharge.

Musculoskeletal: Denies any muscle or joint pain or swelling. Denies weakness. Reports normal exercise.

Psychological: Denies any problems with abnormal mental thoughts, mood, anxiety, stress, depression.

OBJECTIVE DATA

Physical examination

VS: Temp: 101.9oF     BP: 130/74       P: 94      R:28     Wt: 152      Ht:% ft 6 in      BMI: 24.5

General appearance:  Stable mood and able to answer all the questions without hesitation. Well-groomed and in appropriate state of mind. Febrile.

Skin: No signs of lesions, or rashes on the skin. Supple well hydrated skin.

HEENT: Normocephalic, pink conjunctiva. PERRLA. External auditory canals open and tympanic membranes pearly grey, hearing grossly intact. No signs of nasal drainage or swelling. Good dentition, no erythema or lesions. No signs of tonsillar swellings.

NeckLymphatic: Uniform skin complexion. No signs of inflammation. No signs of lymphadenopathy on palpation.

Cardiovascular: Regular heart sounds and rhythm. S3 absent but S1 and S2 present. No heart murmurs noted.

Respiratory: Lung sounds are clear on auscultation bilaterally anterior and posterior.

Gastrointestinal: Sharp pain on the right lower quadrant on palpation. Rovsing’s sign positive with deep palpation of the lower left quadrant. Bowel sounds active x 4 quadrants

Genitourinary: Normal genitally noted with no signs of herniation.

Musculoskeletal: Positive psoas and obturator sign.

Psychological: Maintains good contact while answering all the questions. Seems calm, and responsive throughout physical examination. Mild anxiety noted.

Diagnostics:

  1. Rovsing’s sign
  2. Obturator sign
  3. Psoas sign
  4. HCG

ASSESSMENT

  • Acute lower abdominal pain
  • Differential Diagnosis:
  1. Acute appendicitis: Positive Rovsing’s sign to the right lower quadrant and positive obturator sign by flexing the right hip and knee of the patient to 90° suggests acute appendicitis.
  2. Ectopic pregnancy: lower acute abdominal pain, sexually active with failure for the past 2 months to take OC and inconsistent use of an alternative methods of BC suggest possible ectopic pregnancy.
  3. Pelvic abscess: positive psoas sign, lower abdominal pain suggests psoas abscess.

 

 

 

PLAN

The patient requires further pelvic and lower abdominal examination for a proper diagnosis to assess for any potential gynecological pathology or appendicitis. This will include pelvic and lower abdominal ultrasound. Lab work will include CBC, HCG, UA with C&S, Type and screen for surgical cases and to verify RH status for Rhogam need if pregnancy is non-viable or ectopic. Upon evaluating the radiological and lab data if Acute appendicitis, pelvic abscess or Ectopic pregnancy immediate admission to the hospital with surgical consultation. Acute UTI Bactrim DS 1 tablet po BID x7 days. Follow up in one week if symptoms not resolved.

Education for proper use of birth control and sexually transmitted infection prevention. Reinforcement of avoiding risky behavior like drinking and drug use. Always use seat belts when in a vehicle. Eat a balanced diet and drink 8-10 glasses of water daily.

Differential Diagnosis Illness Script

Illness Scrip Differentiate #1         Acute appendicitis
Epidemiology Acute appendicitis in the United States is one of the most common causes of acute surgical abdominal emergencies. Every year, approximately over 250,000 appendectomies are performed by physicians in America. Nonetheless, the incidence is minimal in areas where people consume high-fiber diets. Among males, the overall lifetime risk of one developing acute appendicitis is approximately 8.6%, but lower in females, 6.7%. consequently, the lifetime risk of undergoing an appendectomy is about 12% in males and higher in females, 23%. In the US, appendectomy rates are about 10 per 10,000 cases every year. Acute appendicitis is most common among teenagers and those in their late 40s. Additionally, there is a slight male to female predominance of about 1.3:1(Jangland, Kitson, & Muntlin, 2016).
Time Course The course of acute appendicitis from onset of initial sign and symptoms to rupture is usually 12 hours to several days.
Clinical Presentation The most common clinical presentation of acute appendicitis is abdominal pain. Initially, the pain is usually peri-umbilical and poorly localized. But with time the pain radiates to the right iliac fossa, where it becomes sharp, localized and persistent. Other symptoms include nausea and vomiting, diarrhea, constipation, and anorexia (Jangland et al., 2016). Additionally, the patient is usually positive for Rovsing’s sign and Psoas sign.
Pathophysiology Appendicitis presents as an acute inflammation of the appendix. The main cause of the inflammation is not clear; however, it is suspected that when the lumen of the appendix becomes blocked by normal fecal matter, a faecolith, or lymphoid hyperplasia as a result of a viral infection. The obstruction reduces the flow of blood to the tissue and hence allowing for bacterial multiplication (El-Radhi, 2015). The obstruction also results in an increase in the pressure within the appendix reducing venous drainage and hence resulting in ischemia. If untreated, the ischemic condition might lead to gangrene or necrosis.
Lab Urinalysis needs to be done for all patients suspected of appendicitis to rule out UTI among other renal/urological cause.

Pregnancy test for all women of reproductive age is also essential.

Routine blood tests, mainly FBC and CRP are important especially in assessing elevated inflammatory markers. A baseline blood test is mainly important for preoperative assessment (Mayumi et al., 2016).

Serum β-Hcg can also be taken in case ectopic pregnancy has not been ruled out.

Imaging Imaging is not very necessary in the diagnosis and treatment of acute appendicitis, as most cases are usually clinically diagnosed. However, a CT scan or trans-abdominal ultrasound can be done in case of inconclusive clinical features.

 

 

Illness Scrip Differentiate #2         Pelvic abscess
Epidemiology A pelvic abscess is a very rare condition. However, some of the main predisposing factors that can result in pelvic abscess include Crohn’s disease, immunodeficiency, pregnancy, and diabetes mellitus. In the case of Crohn’s disease, the abscesses may occur either as a complication of surgery or spontaneously (Mui, Allaire, Williams, & Yong, 2016).
Time Course May take days for the pelvic abscess to grow quite large before the onset of the symptoms.
Clinical Presentation The condition presents with systemic features of toxicity such as malaise, fever, anorexia, nausea and vomiting and pyrexia. Some of the local effects as a result of a pelvic abscess include deep pain and tenderness in a single or both of the lower quadrants, tenesmus, diarrhea, dysuria and mucous discharge per rectum (Kelly, Cullmann, Puig, & Applegate, 2018). Upon rectal examination, tenderness may be revealed on the pelvic peritoneum.
Pathophysiology Pelvic abscess usually occurs as a result of gynecological procedures or infections, or acute appendicitis. It can also present as a complication of diverticulitis, Crohn’s disease or abdominal surgery. The abscess contains pus or infected fluid walled by an inflamed tissue (Yosef et al., 2016). In males, the abscess is usually situated between the rectum and the blooder. In females, the abscess is usually between the posterior fornix of the vagina and the uterus and the rectum posteriorly. Women of productive age usually develop tubo-ovarian abscess that may be a complication of an inflammatory pelvic disease.
Lab FBC: which usually shows raised white blood cell count.
Imaging Ultrasound or CT/MRI scan to locate the origin of the abscess.

 

 

Illness Scrip Differentiate #3         Ectopic Pregnancy
Epidemiology Ectopic pregnancy is thought to occur in around 2% of all pregnancies (The American College of Obstetrics and Gynecology, 2018). However, this number may be grossly inaccurate due to the treatment and management in offices where the incidence is not reported to national surveillance data on ectopic pregnancy (The American College of Obstetrics and Gynecology, 2018). Although many advances have been made in early detection and treatment of ectopic pregnancy. It remains the cause of around 2.7% of maternal deaths nationally (The American College of Obstetrics and Gynecology, 2018).

 

Time Course 6 weeks to 16 weeks gestation to rupture (Dulay, 2017).
Clinical Presentation Vaginal bleeding and pelvic pain without knowledge of pregnancy. Or 1st trimester bleeding with or without pain (Dulay, 2017). Positive rebound tenderness and cervical motion tenderness. Dizziness or fainting may also occur (Barash, Buchanan & Hillson, 2014).
Pathophysiology Ectopic pregnancy is commonly in the fallopian tube, around 90% of extra uterine implantation occur in this location (The American College of Obstetrics and Gynecology, 2018).  The other locations are the abdomen, cervix, ovary, and uterine scars such as prior cesarean scar (The American College of Obstetrics and Gynecology, 2018). It is noted that you can have both an ectopic and intrauterine pregnancy at the same time (The American College of Obstetrics and Gynecology, 2018).

The fetus usually grows in the extrauterine site and ruptures between 6-16 weeks resulting in hemorrhaging to the point of death (Dulay, 2017).

 

 

Lab CBC, β-hCG, Type and Screen (Barash et al., 2014)
Imaging  Pelvic US (Barash et al., 2014)

Documentation of SOAP Format SAMPLE

References

American College of Obstetrics and Gynecology. (2018, March). Tubal Ectopic Pregnancy – ACOG. Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Gynecology/Tubal-Ectopic-Pregnancy?IsMobileSet=false

Dulay, A. (2017, October). Ectopic Pregnancy – Gynecology and Obstetrics – Merck Manuals Professional Edition. Retrieved from https://www.merckmanuals.com/professional/gynecology-and-obstetrics/abnormalities-of-pregnancy/ectopic-pregnancy

El-Radhi, A. S. (January 01, 2015). Management of abdominal pain in children. British Journal of Nursing (mark Allen Publishing), 24 (1), 8-21.

Jangland, E., Kitson, A., & Muntlin, A. A. (April 01, 2016). Patients with acute abdominal pain describe their experiences of fundamental care across the acute care episode: a multi-stage qualitative case study. Journal of Advanced Nursing, (72)4, 791-801.

Joshua H. Barash|Edward M. Buchanan|Christina Hillson. (2014, July 1). Diagnosis and management of ectopic Pregnancy. Retrieved from https://www.aafp.org/afp/2014/0701/p34.html

Kelly, A. M., Cullmann, J. L., Puig, S., & Applegate, K. E. (January 01, 2018). Acute Pelvic Pain in Premenapausal Women, Children and Infants: Evidence-Based Emergency Imaging.

Mayumi, T., Yoshida, M., Tazuma, S., Mizooka, M., Furukawa, A., Nishii, O., Shigematsu, K., … Hirata, K. (January 01, 2016). The Practice Guidelines for Primary Care of Acute Abdomen 2015. Japanese Journal of Radiology, (34)1, 80-115.

Mui, J., Allaire, C., Williams, C., & Yong, P. J. (February 01, 2016). Abdominal Wall Pain in Women With Chronic Pelvic Pain. Journal of Obstetrics and Gynaecology Canada, (38) 2, 154-159.

The Best Symptom Characterizing Symptomatic Uncomplicated Diverticular Disease Of The Colon: A Comparison With Fecal Calprotectin In Clinical Setting. Digestive and Liver Disease: Supplement, (2) 46, 3-8.

Yosef, A., Allaire, C., Williams, C., Ahmed, A. G., Al-Hussaini, T., Abdellah, M. S., Wong, F., … Yong, P. J. (December 01, 2016). Multifactorial contributors to the severity of chronic pelvic pain in women. American Journal of Obstetrics and Gynecology, (215) 6, 34-40.

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