Comprehensive Soap Note Template Essay Paper
Please use the template uploaded. please follow the directions carefully. below is the Pt’s story.
49 year old here for Ed f/u
Was seen in ED on 6/20 for intractable headache and was found to be hyperglycemic with an A1C of 18.1
#Diabetes
New diabetes diagnosis. A1C 18.1 in ED- today 14.1
On metformin 500 mg bid. Started in ED.Taking as prescribed without SEs.
Says his meals usually consist of
Breakfast :orange juice with sugar with fried turnover.
Lunch:Rice beans and meat
Dinner:Rice beans and meat
had increased thirst and urination. states this has resolved since he started taking metformin.
Denies SOB, chest pain, dizziness, palpitations, weakness, nausea, vomiting. Comprehensive Soap Note Template Essay Paper
VS
BP 121/68 Pulse 75 Temp 98.1 °F Wt 175 lb 9.6 oz| SpO2 97% BMI 26.61
Medications: Lipitor 20 mg daily, metformin 1000 mg BID.
immunizations: Tdap:7/7/2022, PCV20 7/7/2022.
Alcohol
Drinks 56 beers per week.
3-5 shots of whisky weekly
6 nips of powerball weekly-stopped 3 weeks ago.
Does not think he has drinking problem, states he can go days without drinking. Denies ever having withdrawal sxs.
Family hx: Mother deceased-diabetes, HTN. Father: alcohol abuse, 1 brother 1 sister : good health. Maternal grandmother: diabetes. Paternal grandfather: prostate cancer.
former smoker:quit 2012.
Comprehensive Notes:
HPI – complete OLD CART information
PMH
PSH
OB/GYN
Mental Health
SH > Tobacco use, Alcohol Use, Drugs, Sexual History
Preventative History
Allergies
Medications
ROS – 6 systems
PE – 8 systems
DD – three for each diagnosis
Plan – Diagnostics
Medications
Referrals
Follow-upRubric Detail
A rubric lists grading criteria that instructors use to evaluate student work. Your instructor linked a rubric to this item and made it available to you. Select Grid View or List View to change the rubric’s layout.
Content
Name: PRAC_6565_Week8_Assignment1_Rubric
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List View
Excellent Good Fair Poor
Create documentation in the Comprehensive SOAP Note Template about the patient you selected.
In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Current medications
• Allergies
• Patient medical history (PMHx), including immunization status, social and substance history, family history, past surgical procedures, mental health, safety concerns, reproductive history
• Review of systems
Points Range:9 (9.00%) – 10 (10.00%)
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis.
Points Range:8 (8.00%) – 8 (8.00%)
The response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis.
Points Range:7 (7.00%) – 7 (7.00%)
The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies.
Points Range:0 (0.00%) – 6 (6.00%)
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing.
In the Objective section, provide:
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• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history Comprehensive Soap Note Template Essay Paper
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
Points Range:9 (9.00%) – 10 (10.00%)
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
Points Range:8 (8.00%) – 8 (8.00%)
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.
Points Range:7 (7.00%) – 7 (7.00%)
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.
Points Range:0 (0.00%) – 6 (6.00%)
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
In the Assessment section, provide:
• At least 3 differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.
Points Range:23 (23.00%) – 25 (25.00%)
The response lists at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected.
Points Range:20 (20.00%) – 22 (22.00%)
The response lists at least three different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the conditions selected.
Points Range:18 (18.00%) – 19 (19.00%)
The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.
Points Range:0 (0.00%) – 17 (17.00%)
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
In the Plan section, provide:
• A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits.
• Reflections on the case describing insights or lessons learned.
• A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors.
Points Range:27 (27.00%) – 30 (30.00%)
The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. Reflections on the case demonstrate strong critical thinking and synthesis of ideas. A thorough and accurate disucssion of health promotion and disease prevention related to the case is provided.
Points Range:24 (24.00%) – 26 (26.00%)
The response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. Reflections on the case demonstrate critical thinking. An accurate disucssion of health promotion and disease prevention related to the case is provided.
Points Range:21 (21.00%) – 23 (23.00%)
The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. Reflections on the case demonstrate adequate understanding of course topics. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies. Comprehensive Soap Note Template Essay Paper
Points Range:0 (0.00%) – 20 (20.00%)
The response does not address all diagnoses or is missing elements of the treatment plan. Reflections on the case are vague or missing. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing.
Provide at least three evidence-based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than five years old) and support the treatment plan in following current standards of care.
Points Range:9 (9.00%) – 10 (10.00%)
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions.
Points Range:8 (8.00%) – 8 (8.00%)
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions.
Points Range:7 (7.00%) – 7 (7.00%)
Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan.
Points Range:0 (0.00%) – 6 (6.00%)
Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence-based, or do not support the treatment plan.
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
Points Range:5 (5.00%) – 5 (5.00%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. Comprehensive Soap Note Template Essay Paper
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):
“I’m here for my diabetes”
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 seven attributes of each principal symptom:
- Location
- Quality
- Quantity or severity
- Timing, including onset, duration, and frequency
- Setting in which it occurs
- Factors that have aggravated or relieved the symptom
- 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, ADLs and IADLs 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. Comprehensive Soap Note Template Essay Paper
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.
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 if 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, height, weight, 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, 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:
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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:
Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, X-rays, or other diagnostics. Support the treatment plan with evidence and guidelines. Comprehensive Soap Note Template Essay Paper
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?
References
American Diabetes Association. (2021). 2. Classification and diagnosis of diabetes: standards of medical care in diabetes—2021. Diabetes care, 44(Supplement 1), S15-S33. https://doi.org/10.2337/dc21-s002
Fruh, S. M. (2017). Obesity. Journal of the American Association of Nurse Practitioners, 29(S1), S3-S14. https://doi.org/10.1002/2327-6924.12510
Han, M., Li, Q., Liu, L., Zhang, D., Ren, Y., Zhao, Y., Liu, D., Liu, F., Chen, X., Cheng, C., Guo, C., Zhou, Q., Tian, G., Qie, R., Huang, S., Wu, X., Liu, Y., Li, H., Sun, X., … Hu, D. (2019). Prehypertension and risk of cardiovascular diseases. Journal of Hypertension, 37(12), 2325-2332. https://doi.org/10.1097/hjh.0000000000002191
Lv, Z., & Guo, Y. (2020). Metformin and its benefits for various diseases. Frontiers in Endocrinology, 11. https://doi.org/10.3389/fendo.2020.00191
Matoori, S. (2022). Diabetes and its Complications. ACS Pharmacology & Translational Science.
Mouri, M., & Badireddy, M. (2021). Hyperglycemia. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430900/
Tynan, A. (2020). Supporting positive lifestyle changes among patients with diabetes mellitus type 2. https://doi.org/10.33015/dominican.edu/2020.nurs.st.14
Comprehensive Soap Note Template Essay Paper
