Nursing Homework week 6: SOAP NOTE

40-year-old female Hispanic with congestion, facial pain, postnasal drip, and frontal headache for 10 days. Thick yellow nasal discharge and mild fatigue. No fever, sore throat, or cough denied. No allergies or chronic sinus disease. Physical exam: erythematous and swollen nasal mucosa, tender over maxillary sinuses, mildly erythematous throat, clear lungs. Vitals stable and afebrile. Assessment consistent with acute bacterial sinusitis. Treated with amoxicillin-clavulanate 875/125 mg PO BID for 7 days, saline nasal spray PRN, hydration, and warm compresses. Instructed to complete antibiotics, monitor for worsening symptoms, and follow up if no improvement in 7–10 days. Patient verbalized understanding and agreement with plan.

· Type of Visit: New Consult

· Reason for Visit: Nasal congestion, facial pressure, and headache

· Chief Complaint: “I’ve had sinus pressure, stuffy nose, and a headache for over a week.”

· Type of H&P: Problem-focused

· Time with Patient: 25 minutes

· Consult with Preceptor: 10 minutes

· Decision-Making Type: Low to moderate complexity

Clinical Notes:

40-year-old Hispanic female presents with nasal congestion, facial pain, postnasal drip, and frontal headache for 10 days. Reports thick yellow nasal discharge and mild fatigue. Denies fever, sore throat, or cough. No history of chronic sinus disease or allergies. Physical exam: nasal mucosa erythematous and swollen, tenderness over maxillary sinuses, throat mildly erythematous, lungs clear. Vitals stable and afebrile. Assessment consistent with acute bacterial sinusitis. Treatment initiated with amoxicillin-clavulanate 875/125 mg PO twice daily for 7 days, saline nasal spray as needed, hydration, and warm compresses. Advised to complete antibiotics, monitor for worsening symptoms, and follow up if not improved in 7–10 days. Patient verbalized understanding and agreement with plan.

Social Problems Addressed:

☑ Prevention ☑ Safety ☑ Nutrition/Exercise

ICD-10 Diagnosis Codes:

1. J01.00 – Acute maxillary sinusitis, unspecified

2. R51.9 – Headache, unspecified

CPT® Billing Codes:

1. 99213 – Office or other outpatient visit for the evaluation and management of an established patient, low to moderate complexity

2. 87880 – Infectious agent antigen detection by immunoassay (rapid strep test, if performed to rule out pharyngitis)

Medications:

· New/Refilled Rx this visit:

· Amoxicillin-clavulanate 875/125 mg PO twice daily for 7 days

· Fluticasone nasal spray, 1 spray each nostril daily PRN congestion

· OTC Drugs: Saline nasal spray, acetaminophen as needed

Adherence Issues with Medications:

☑ Knowledge deficit (education on completing antibiotics)

Procedures/Skills Observed/Performed:

☑ Physical Assessment ☑ ENT Exam ☑ Patient Education/Counseling

,

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor:

Soap Note # ____ Main Diagnosis ______________

PATIENT INFORMATION

Name:

Age:

Gender at Birth:

Gender Identity:

Source:

Allergies:

Current Medications: (including OTC and vitamins)

·

PMH:

Immunizations:

Preventive Care: Preventive Screenings: (for results already obtained before this encounter) – Pap smear: ______ – Mammogram: ______ – Colonoscopy: ______ – Lipid panel: ______ – A1C: ______ – STI screen: ______ – Depression screen (PHQ-9): ______

Surgical History:

Family History:

Social History:

Sexual Orientation:

Nutrition History:

SUBJECTIVE DATE

Chief Complaint (which must be stated between “__”)

Symptom analysis/HPI:

Clinical Tools Used (if applicable), otherwise state N/A – PHQ-9: ___ /27 – GAD-7: ___ /21 – AUDIT-C / DAST:

Review of Systems (ROS) (This section is what the patient says, therefore it should state “Pt denies… or Pt states…”)

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL:

SKIN:

OBJECTIVE DATA

VITAL SIGNS: LABS / DIAGNOSTICS REVIEWED (if available): – CBC: – Lipid Panel: – A1C: – EKG: – Imaging (if done):

GENERAL APPREARANCE:

NEUROLOGIC:

HEENT:

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:

ASSESSMENT

Red Flags / Reasons for Escalation: – [ ] None noted – [ ] Positive suicidal ideation – [ ] Unstable vital signs – [ ] Abnormal exam requiring urgent referral

Clinical Note

(In a paragraph you should state “your encounter with your patient and your findings (including subjective and objective data)

Example: “Pt came into our clinic today c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… On examination I noted erythema in the ear canal…, this, and that etc.)

Main Diagnosis

(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.

Differential diagnosis (minimum 3) along with the rationale behind them. (why you decide to include these differential diagnosis for this patient? What part of your assessment supports them?)

–

–

–

PLAN

Labs and Diagnostic Test to be ordered (if applicable)

· –

· –

Pharmacological treatment:

–

Non-Pharmacologic treatment:

Education (provide the most relevant ones – tailored to this specific patient – not in general)

Follow-ups/Referrals

Visit Complexity / CPT Code: _______

References (in APA Style)

Examples

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).

ISBN 978-0-8261-3424-0

Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010

(25th ed.). Print (The 5-Minute Consult Series).

NP Women’s Health Weekly Clinical Experience 1