Soap Note 1 is based on the Case Study # 1 ATTACHED (10 Points)
You MUST use the Case Study #1 as the base of this SOAP NOTE #1
Must use the sample template for your soap note,(ATTACHED)
Student must use the template provided. No passing grade will be granted if this section is not completed properly.
Follow the MRU Soap Note Rubric as a guide
Use APA format and must include minimum of 2 Scholarly Citations.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in Score must be less than 15% or will not be accepted for credit, must be your own work and in your own words.
The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.
3 pages
due date June 4, 2024
Grading Rubric
Student______________________________________
This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.
1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.
2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following:
a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).
b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).
c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.
3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.
a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).
b) Pertinent positives and negatives must be documented for each relevant system.
c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).
5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.
6) Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.
7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?
Comments:
Total Score: ____________ Instructor: __________________________________
Guidelines for Focused SOAP Notes
· Label each section of the SOAP note (each body part and system).
· Do not use unnecessary words or complete sentences.
· Use Standard Abbreviations
S: SUBJECTIVE DATA (information the patient/caregiver tells you).
Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis, physician-recommended return(s) for this patient visit. The patient’s own words should be in quotes.
History of present illness (HPI): a chronological description of the development of the patient's chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last patient encounter.
Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-appropriate immunization status.
Family History (FH): Update significant medical information about the patient's family (parents, siblings, and children). Include specific diseases related to problems identified in CC, HPI or ROS.
Social History(SH): An age-appropriate review of significant activities that may include information such as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of education and sexual history.
Review of Systems (ROS). There are 14 systems for review. List positive findings and pertinent negatives in systems directly related to the systems identified in the CC and symptoms which have occurred since last visit; (1) constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13) hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE findings section.
0: OBJECTIVE DATA (information you observe, assessment findings, lab results).
Sufficient physical exam should be performed to evaluate areas suggested by the history and patient's progress since last visit. Document specific abnormal and relevant negative findings. Abnormal or unexpected findings should be described. You should include only the information which was provided in the case study, do not include additional data.
Record observations for the following systems if applicable to this patient encounter (there are 12 possible systems for examination): Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lymphatic/immunologic/lab testing. The focused PE should only include systems for which you have been given data.
NOTE: Cardiovascular and Respiratory systems should be assessed on every patient regardless of the chief complaint.
Testing Results: Results of any diagnostic or lab testing ordered during that patient visit.
A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code)
List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.
Remember: Your subjective and objective data should support your diagnoses and your therapeutic plan.
Do not write that a diagnosis is to be "ruled out" rather state the working definitions of each differential or primary diagnosis (es).
For each diagnoses provide a cited rationale for choosing this diagnosis. This rationale includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the focused PE findings and tests results that support the dx. Include the interpretation of all lab data given in the case study and explain how those results support your chosen diagnosis.
P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include an EBP citation.
1. Medications write out the prescription including dispensing information and provide EBP to support ordering each medication. Be sure to include both prescription and OTC medications.
2. Additional diagnostic tests include EBP citations to support ordering additional tests
3. Education this is part of the chart and should be brief, this is not a patient education sheet and needs to have a reference.
4. Referrals include citations to support a referral
5. Follow up. Patient follow-up should be specified with time or circumstances of return. You must provide a reference for your decision on when to follow up.
,
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C
Soap Note # ____ Main Diagnosis ______________
PATIENT INFORMATION
Name:
Age:
Gender at Birth:
Gender Identity:
Source:
Allergies:
Current Medications:
·
PMH:
Immunizations:
Preventive Care:
Surgical History:
Family History:
Social History:
Sexual Orientation:
Nutrition History:
Subjective Data:
Chief Complaint:
Symptom analysis/HPI:
The patient is …
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL:
NEUROLOGIC:
HEENT:
RESPIRATORY:
CARDIOVASCULAR:
GASTROINTESTINAL:
GENITOURINARY:
MUSCULOSKELETAL:
SKIN:
Objective Data:
VITAL SIGNS:
GENERAL APPREARANCE:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted 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)
–
–
–
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
· –
· –
Pharmacological treatment:
–
Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
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).
image1.png
,
CASE STUDY 1 IRON DEFICIENCY ANEMIA
Case Study: Iron Deficiency Anemia Patient Information:
• Name: John Doe • Age: 35 • Gender: Male •
Occupation: Construction Worker •
Medical History: No significant medical history reported.
Presenting Complaint: John Doe presents to the clinic with complaints of fatigue,
weakness, and shortness of breath on exertion for the past few months. He reports feeling
unusually tired, even after a full night's sleep, and has noticed increased paleness of his skin and
conjunctiva.
Physical Examination Findings: • Vital Signs: BP 120/80 mmHg, HR 80 bpm, RR 16
breaths/min, Temp 98.6°F
• General: Pale skin and conjunctiva, fatigue apparent • Cardiovascular: Regular rhythm,
no murmurs or abnormal sounds • Respiratory: Clear lung fields bilaterally • Abdomen: Soft,
non-tender, no organomegaly • Neurological: Intact cranial nerves, normal motor and sensory
functions
Laboratory Investigations: • Hemoglobin (Hb): 9.5 g/dL (Normal range: 13.5-17.5 g/dL) •
Hematocrit (Hct): 29% (Normal range: 40-50%) • Mean Corpuscular Volume (MCV): 75 fL
(Normal range: 80-100 fL) • Serum Iron: 25 mcg/dL (Normal range: 60-170 mcg/dL) • Total Iron
Binding Capacity (TIBC): 400 mcg/dL (Normal range: 250-450 mcg/dL) • Ferritin: 10 ng/mL
(Normal range: 30-400 ng/mL)
Diagnosis: John Doe is diagnosed with iron deficiency anemia based on his clinical
presentation, physical examination findings, and laboratory results.
Questions for Students: 1. What are the common signs and symptoms of iron deficiency
anemia?
2. Explain the laboratory findings in John Doe's case and how they support the diagnosis
of iron deficiency anemia.
3. What are the potential causes of iron deficiency anemia in adults, and how would you
approach further investigations in this patient?
4. Discuss the treatment options for iron deficiency anemia, including dietary
recommendations and pharmacological interventions.
1. Iron deficiency anemia manifests in multiple symptoms. Fatigue, shortness of breath,
angina, and tachycardia are common symptoms of iron deficiency anemia (Kumar et al., 2022).
The reduced blood oxygen levels cause chest pains and tachycardia. One could also have
reduced intestinal blood flow due to the resultant hypoxemia, causing abdominal pain, weight
loss, and nausea (Kumar et al., 2022). Insufficient blood levels also result in brittle nails and pale
skin. Therefore, the symptoms the patient presented with, such as fatigue, shortness of breath,
pale skin, and chest exertion, suggest the condition.
2. The patient's blood components are off the normal levels. His hemoglobin is below the
normal range. Low hemoglobin levels are a significant indicator of iron deficiency anemia
(Kumar et al., 2022). The patient's hematocrit, ferritin, Mean Corpuscular Volume (MCV), and
serum iron levels are also low, suggesting iron deficiency anemia. However, the Total Iron
Binding Capacity is high, a condition common in iron deficiency anemia, due to
the body's increased attempt to transport iron. MCV is useful for differential diagnosis between
anemias because it determines the average size of the red blood cells.
3. Like the patient, iron deficiency anemia could result from multiple factors in
adults. First, iron is dependent on dietary intake (Kumar et al., 2022). Therefore, poor nutrition
and consuming foods low in iron are potential causes of the condition. Still, mensuration may
cause the condition. Menstruating women are thus a high-risk population for iron deficiency
anemia (Belali, 2022). In addition, digestive system problems, such as malabsorption, can cause
iron deficiency anemia when the body cannot absorb enough iron. Gastrointestinal conditions
like hemorrhoids and ulcers (capable of causing gastrointestinal bleeding) could also contribute
to iron deficiency anemia. Conversely, inquiring about the patient’s iron intake can help to
understand the contributions to his condition. Furthermore, a fecal occult blood test is important
because a positive result indicates bleeding somewhere in his gastrointestinal area. The chronic
bleeding produces anemia. This result leads to future gastroenterology reference (endoscopy and
CT scan).
4. Dietary changes to consume iron-rich foods are a primary part of the treatment for the
patient. A healthy diet constitutes about 1–5 mg of heme iron and 5 to 10mg of elemental iron
(Kumar et al., 2022). Foods with high iron content include leafy greens (broccoli, kale, brussels
sprouts) red pepper, beans, lentils, and lean meat including others. Fruits with elevated iron
content involve are fig, dates, raising, prunes, pomegranate, raspberries; moreover, fruits such as
kiwi, strawberries, oranges, lemon, grapefruit, blackcurrant, between others help with the
absorption of the iron because the high Vitamin C that it has. The treatment depends on the
etiology of the anemia and the patient response to his treatment. All the patients are individuals.
However, the patient should also take oral supplements of iron such as ferrous gluconate, sulfate,
fumarate and has the option of IM or IV injection. Also, it is very important to indicate to the
patient the side effects of the supplement iron such as dark stool, constipation, metallic taste,
upset stomach among others.
References
Belali, T. M. (2022). Iron deficiency anemia: prevalence and associated factors among residents
of northern Asir Region, Saudi Arabia. Scientific Reports, 12(1), 19170. https://
www.nature.com/articles/s41598-022-23969-1
Kumar, A., Sharma, E., Marley, A., Samaan, M. A., & Brookes, M. J. (2022). Iron deficiency
anemia: pathophysiology, assessment, practical management. BMJ open
gastroenterology, 9(1), e000759. https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC8744124/
You MUST use the Case Study #1 as the base of this SOAP NOTE #1