Submit a Problem-Focused SOAP note here for grading.  You must use an actual patient from your clinical practicum.  Review the rubric for more information on how your assignment will be graded. Please use a psychiatric patient (example of diagnosis GAD, MDD, PTSD

 

SOAP Note Template

(Use this template for this assignment)

 

Demographic Data

· Patient age and gender identity

· MUST BE HIPAA compliant.

Subjective

Chief Complaint (CC)

· Place the complaint in Quotes

· Brief description -only a few words and in the patient’s words…“My chest hurts”, “I cannot breath”, “I passed out”, etc.

History of Present Illness (HPI) – the reason for the appointment today

· Use the OLD CARTS acronym to document the eight elements of a chief concern (CC): Onset, Location/radiation, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity)

· Briefly describe the general state of health prior to the problem.

· Are Activities of Daily Living (ADL) impacted by the current problem?

 

Past Medical History:

· List current and past medical diagnoses

 

Past Surgical History:

· List all past surgeries

 

FAMILY HISTORY:

· Include medical/psychiatric problems to include 3 generations (parents, grandparents, siblings, or direct relatives.

 

Current Medications:

· Include current prescription(s), over-the-counter medications, herbal/alternative medications as well as vitamin/supplement use.

 

ALLERGIES: Include medications, foods, and chemicals such as latex.

 

Immunizations History: List current immunization status and address deficiency

SOCIAL HISTORY:

· Include nutrition, exercise, substance use (details of use: caffeine, EtOH, illicit drug use), sexual history/preference, financial problems, legal issues, kids, and history of abuse, including sexual, emotional, or physical.

· Employment/Education: occupation (type), exposure to harmful agents, highest school achievement

 

 

REVIEW OF SYSTEMS:

· A ROS is a question-seeking inventory by body systems to identify signs and/or symptoms that the patient may be experiencing or has experienced.

· Must include any physical complaint(s) by the body system that is relevant to treatment and management of the current concern(s). List only the pertinent body systems specific to the CC.

· Remember to include pertinent positive and negative findings when detailing the ROS related to a chief concern (CC).

· Do not repeat the information provided in HPI

 

Use the format below when detailing the ROS

 

 

ROS:

 

General:

Eyes:

Ears, nose, mouth & throat:

Cardiovascular:

Respiratory:

Gastrointestinal:

Skin & Breasts:

Musculoskeletal:

Allergic:

Immunologic:

Endocrine:

Hematopoietic/Lymphatic:

Genitourinary:

Neurological:

Psychiatric/Mental Status:

Objective

PHYSICAL EXAMINATION: Document by Body System including vital signs and pertinent diagnostics.

 

General:

Eyes:

Ears, nose, mouth & throat:

Cardiovascular:

Respiratory:

Gastrointestinal:

Skin & Breasts:

Musculoskeletal:

Allergic:

Immunologic:

Endocrine:

Hematopoietic/Lymphatic:

Genitourinary:

Neurological:

Psychiatric/Mental Status:

 

Assessment (Diagnosis)

Differential Diagnosis (DDx)

· Include two (2) differential diagnoses (including ICD 10 code) you considered but did not select as the final diagnosis.

· Why were these 2 diagnoses not selected? Support with pertinent positive and negative findings for each differential and support with 2 evidence-based guidelines.

 

Working or Final Diagnosis:

· Final or working diagnosis (including ICD-10 code)

· Provide a rational explanation supported with evidenced-based guidelines (required). List the pertinent positive and negative symptoms/signs that support your final diagnosis.

 

 

 

 

Plan

Treatment (Tx) Plan: pharmacologic and/or nonpharmacologic

· Pharmacologic -include full prescribing information for each medication(s) ordered

· Refill Provided: Include full prescribing information for each medication(s) refilled and the correlating diagnosis related to the refill.

 

Patient Education:

· include specific education related to each medication prescribed.

· Was risk versus benefit of current treatment plan addressed for medication(s) and interventions? Was the patient included in the medical decision making and in agreement with the final plan

· NPs should not be prescribing non-FDA approved medications or medications related to off-label use. If a physician prescribed a non-FDA-approved medication for working diagnosis or recommended off-label use was education provided and was the risk to benefit of the medication(s) addressed in the patient’s education?

 

Prognosis Good, Fair, or Poor?

· Indicate the patient’s prognosis: Good, Fair, Poor

· Provide support for your selected prognosis.

 

Referral/Follow-up

· Did you recommend follow-up with PCP, or consultation with other healthcare professionals?

· When is the subsequent follow-up?

· Include rationale for the follow-up recommendation or referral.

 

Disposition:

· Indicate the disposition of the patient.

· Was the patient sent home, Emergency room via EMS, etc.

Reference(s)

· Include APA formatted references.

· Minimum 2 references are required from evidence-based resources.