Topic: Soap note on Respiratory patient

Order Description

Practicum Experience: SOAP Note 11

After completing this week’s Practicum Experience, select a patient that you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:
•   Subjective: What details did the patient provide regarding his or her personal and medical history?
•   Objective: What observations did make during the physical assessment?
•   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 including alternative therapies?
•   Reflection notes: What would you do differently in a similar patient evaluation?
Example of Soap Note
Nurse Practitioner SOAP Notes
Purpose: To explain what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.
SUBJECTIVE DATA: What the patient tells you but organized by you in logical fashion
Chief Complaint (CC): One to three words explaining why patient came to clinic
History of Present Illness (HPI): Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, gender. (Example: 34-year-old AA male) Must include the 7 attributes of each principal symptom:
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: list each one by name with dosage and frequency
Allergies: include specific reactions to medications, foods, insects, environmental
Past Medical History (PMH): Illnesses, hospitalizations, risky sexual behaviors. Include childhood illnesses
Past Surgical History (PSH): Dates, indications and types of operations
OB/GYN History: (if applicable) Obstetric history, menstrual history, methods of contraception and sexual function
Personal/Social History: Tobacco use, Alcohol use, Drug use. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits
Immunizations: Last Tdp, Flu, pneumonia, etc.
Family History: Parents, Grandparents, siblings, children
Review of Systems: Go Head to toe. Cover each system that covers the Chief Complaint, History of Present Illness and History (this includes the systems that address any previous diagnoses). YOU DO NOT NEED TO DO THEM ALL UNLESS YOU ARE DOING a TOTAL H&P. Remember, this is what the patient tells you.
General: any recent weight changes, weakness, fatigue, or fever
Skin: rashes, lumps, sores, itching, dryness, changes, etc.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular:
Gastrointestinal:
Peripheral vascular:
Urinary:
Genital:
Musculoskeletal:
Psychiatric:
Neurological:
Hematologic:
Endocrine:

OBJECTIVE DATA: This is what you see, hear, feel when doing your physical exam. Again, you go head to toe and 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.
Here is where the vital signs go. Include ht and wt and BMI
General: General state of health, posture, motor activity and gait. Dress, grooming, hygiene. Odors of body or breath. Facial expression, manner, affect and reactions to people and things. Level of conscience.
SKIN:
HEENT:
Neck:
Chest/Lungs: ALWAYS INCLUDE IN YOUR PE
Heart/Peripheral Vascular: ALWAYS INCLUDE THE HEART IN YOUR PE
Abdomen:
Genital:
Musculoskeletal:
Neurological:

ASSESSMENT: Need to list your priority diagnosis(es) first. For each priority diagnosis, list at least 3 differential diagnoses. Support your selection with evidence.
Example: Migraine headache (tension headache, cluster headache, brain tumor)
Hypertension (renal disease, stress, renal artery stenosis)
For holistic care you need to include previous diagnoses and indicate whether these are controlled or not controlled and remember to include that in your treatment plan.
What evidence or guidelines did you use to support your diagnoses?
PLAN: Treatment plan. Labs, x-rays, etc. Include both pharmacological and nonpharmacological strategies. Include alternative therapies. When do they need to follow-up? Any referrals? Consultations?
Health Promotion: What does the patien/ family need to do to promote their health? Exercise, healthy diet, safety, etc.
Disease Prevention: For the patient’s age, what needs to be done to detect disease early…fasting lipid profile, mammography, colonoscopy, immunizations, etc.
What evidence did you use to support your treatment plan?
REFLECTION: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence? Really think about what you are doing in clinical.