Week 10 Assignment
Practicum: SOAP Note and Time Log
Select a patient who you examined during the last 4 weeks. With this patient in mind, address the following in a SOAP Note:
• Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.
• Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
• Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
• Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
Please reflect on a patient with a Urinary Tract infection to complete the following SOAP NOTE
Readings
• Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013). Pediatric primary care(5th ed.). Philadelphia, PA: Elsevier.
o Chapter 34, “Genitourinary Disorders” (pp. 809–843)
This chapter presents information related to the anatomy and physiology of the genitourinary system. It then explores assessment and management strategies for genitourinary disorders, including common genitourinary conditions in males.
o Chapter 35, “Gynecologic Disorders” (pp. 844–876)
This chapter explores female anatomy and physiology from gestation through puberty and adolescence. It also provides information related to anticipatory guidance, adolescent pregnancy prevention, contraceptive use, and assessment and management strategies for disorders.
• American Academy of Pediatrics, Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. (2011). Urinary tract infection: Clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics,128(3), 595–610. Retrieved from http://pediatrics.aappublications.org/content/128/3/595.full?sid=cc35023c-502d-474a-9856-bfb5e38eed54
This article provides guidelines for diagnosing and managing urinary tract infections in febrile infants and young children. It also describes criteria for selecting appropriate treatment options.
• Cox, A. M., Patel, H., & Gelister, J. (2012). Testicular torsion. British Journal of Hospital Medicine, 73(3), C34–C36.
Retrieved from the Walden Library Databases.
Comprehensive SOAP Template
Patient Initials: _______ Age: _______ Gender: _______
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 (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list:
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. Identify if it is an allergy or intolerance.
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, and. risky sexual behaviors.
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 Tdap, Flu, pneumonia, etc.
Significant Family History: Include history of parents, grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference.
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 . Pulse Ox, Pain level.
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 consciousness, 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:
Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses IF YOU ALREADY HAVE RESULTS.
ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least three 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 non-pharmacological 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? This is worth 25 points!
References: Should use two peer-reviewed journal articles or references to support your reflection and differentials as well as any textbooks used.
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