Comprehensive SOAP Template
Patient Initials: _______ Age: _______ Gender: _______
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Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
O = onset of symptom (acute/gradual)
L= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= treatments previously tried – response? Why discontinued?
S= severity
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.
History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies: Include specific reactions to medications, foods, insects, and environmental factors.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.
Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
Immunization History: Include last Tdp, Flu, pneumonia, etc.
Significant Family History: Include history of parents, Grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and support systems.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.
Hematologic:
Endocrine:
Allergic/Immunologic:
OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.
Physical Exam:
Vital signs: Include vital signs, ht, wt, and BMI.
General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.
HEENT:
Neck:
Chest/Lungs: Always include this in your PE.
Heart/Peripheral Vascular: Always include the heart in your PE.
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.
Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.
Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.
Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.
REFLECTION: Reflect on your clinical experience and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence?
Week 4 Lab Assignment: Differential Diagnosis for Skin Conditions
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Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions
Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.
In this Lab Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.
To Prepare
· Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.
· Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
· Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
· Consider which of the conditions is most likely to be the correct diagnosis, and why.
· Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.
· Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to guide you as you prepare your SOAP note.
· Download the SOAP Template found in this week’s Learning Resources, and use this template to complete this Lab Assignment.
The Lab Assignment
· Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
· Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources.
© 2019 Walden University Page 2 of 3
Running head: PHARMACOTHERAPY 1
PHARMACOTHERAPY 4
Pharmacotherapy
Tina Cherry
Walden University
Advanced Health Assessment & Diagnostic Reasoning NURS 6512C
Dr. Brown
December 27, 2020
Diagnosis
Hepatitis C is a viral disease that leads to the swelling or inflammation of the liver. It is caused by Hepatitis C virus and the disease is transmitted through long-term kidney dialysis, or having regular contact with blood at work such as a health care worker, have unprotected sex with someone infected with hepatitis C, use of injected street drugs, and share a needle with someone who has hepatitis C. Its symptoms include itchy skin, poor appetite, ease of bleeding and fatigue. On the other hand, gastrointestinal tract disorder refers to any health problem that occurs in the digestive tract characterized with symptoms such as fatigue, nausea, vomiting and diarrhea. Hepatitis C and gastrointestinal tract disorder can occur at the same time and therefore referred to as multiple disorders that have some symptoms commonalities.
Plan Based on the Patient’s History and Diagnosis
There are several diagnosis tests for Hepatitis C. One of the tests is the Magnetic resonance elastography commonly known as the MRE. It combines magnetic resonance imaging technology with various patterns formed by sound waves that bounce off the liver, thus creating a visual map showing gradients of stiffness throughout the liver. Diagnosis of gastrointestinal tract disorder is a very sensitive process that requires accurate medical history of the patient, symptoms experienced among other significant information. One of the diagnosis tests for gastrointestinal tract disorder is the endoscopy that involves the insertion of a long, flexible tube referred to as the endoscope with a tiny camera down the throat and into the esophagus to enable the medical provider examines the esophagus, stomach, and the small intestines.
For effective treatment of hepatitis C and gastrointestinal tract disorder, the medical provider should consider the patient’s medical history like the drugs prescribed, and an individual patient factor such as drug abuse to develop an effective treatment for the disorder. Antihistamine or anticholinergic such as diphenhydramine is the other drug therapy. It is administered at 25-50mg at an interval of six to eight hours. Diphenhydramine drug therapy causes drowsiness, confusion and dry mouth. Promethazine is administered to a patient with hepatitis C at an interval of four to six hours as prescribed. This particular drug therapy is associated with negative effects such as sedation,agitation, dry mouth and blurred vision. Gastrointestinal disorder is treated by proton pump that uses the energy of ATP to secrete protons into the stomach and suppresses acid secretion.
Conclusion
This patient has a known drug abuse history and possible Hepatitis C disease. We should ask about the type, amount, method, and time of last substances used to see if symptoms are related to prior use or withdrawal. Withdrawal symptoms may include agitation, anxiety, muscle aches, sweating, abdominal cramping, diarrhea, nausea, and vomiting (Ba, 2019). These drug therapies are recommendable for a patient who is a drug abuser and is nauseous because promethazine is used to prevent and treat nausea and vomiting related to drug abuse. Diphenhydramine is an antihistamine also used to prevent and treat nausea, vomiting and dizziness caused by motion sickness.
References
Ba, C. (2019). Prescription drug addiction. Salem Press Encyclopedia of Health. Retrieved from
https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=
ers&AN=94415512&site=eds-live&scope=site
Kirgyez N. Z. (2020). Hepatitis C virus prevalence and level of intervention required to achieve the WHO targets for elimination in the European Union
by 2030. Modern pharmacotherapy of chronic hepatitis C in patients who failed to achieve sustained virologic response, 2 (5), 325-336
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