PRAC 6552: Advanced Nurse Practice in Reproductive Health Care
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.”
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. Use LOCATES Mnemonic to complete your HPI. You need to start every HPI with age, race, and gender (e.g., 34-year-old African American female). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed. Soc & Substance Hx: Include occupation and major hobbies, family status, vaping, tobacco and alcohol use (previous and current use, how many times a day, how many years), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.
Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual—current and historical).
Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used), Sexually active? types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any sexual concerns.
ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching. Breast-lumps, pain, discharge?
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.
GENITOURINARY: Burning on urination. Breast-lumps, pain, discharge? No reports of vaginal discharge, pain?
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam: From head to toe, include what you see, hear, and feel when conducting your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT:).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
A .
Primary and Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
P.
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. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?
Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).
References
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
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It seems like you are looking to create a SOAP note based on the provided template for a patient with a chief complaint. Here’s an example following the template structure provided:
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**Patient Information:**
– Initials: JW
– Age: 20 years
– Sex: Female
– Race: Caucasian
**S.**
– **CC (Chief Complaint):** “Feeling extremely energized and restless, unable to sleep.”
– **HPI (History of Present Illness):**
– 20-year-old Caucasian female presents with a chief complaint of restlessness and inability to sleep for the past four nights. She appears excessively energetic, pacing around, and feels she has too much to accomplish. She recently lost her job as a tattoo artist and has impulsively purchased a $20,000 car and a $40,000 van to start a mobile tattoo business in Naples, Florida. She states, “I’m too important to waste time in the ED.”
**LOCATES Mnemonic:**
– **Location:** Behavioral changes noted at home and in the community.
– **Onset:** Symptoms started gradually over the past week.
– **Character:** Restlessness, rapid speech, grandiose ideas of business ventures.
– **Associated signs and symptoms:** Decreased need for sleep, increased energy, impulsivity.
– **Timing:** Symptoms have been worsening over the past four days.
– **Exacerbating/relieving factors:** Increased activity exacerbates symptoms; lack of sleep contributes to persistent restlessness.
– **Severity:** Patient rates her symptoms as significantly impairing daily functioning, 8/10 on a subjective scale.
**O.**
– **Physical Exam:**
– General: Patient is alert, oriented x3, appears restless.
– Neurological: Speech is rapid and pressured.
– Cardiovascular: Regular rate and rhythm, no murmurs.
– Respiratory: Clear breath sounds bilaterally.
– Abdominal: Soft, non-tender, non-distended.
– **Diagnostic Results:**
– Comprehensive metabolic panel (CMP) within normal limits.
– Urine toxicology screen negative for substances of abuse.
**A.**
– **Primary Diagnosis:** Bipolar Disorder, Current Episode Manic, Severe with Psychotic Features
– Supported by DSM-5 criteria for manic episodes, including elevated mood, increased energy, grandiosity, and decreased need for sleep.
– **Differential Diagnoses:**
1. Substance-induced mood disorder (amphetamine use disorder)
2. Generalized anxiety disorder
3. Psychotic disorder due to another medical condition
**P.**
– **Plan:**
– **Diagnostic Studies:** None additional at this time.
– **Therapeutic Interventions:**
– Start pharmacological treatment with lithium carbonate 300mg twice daily to stabilize mood.
– Initiate psychoeducation for patient and family about bipolar disorder and its management.
– **Disposition:** Admit to psychiatric inpatient unit for stabilization and safety monitoring.
– **Follow-up:** Weekly outpatient psychiatric visits for medication titration and therapy sessions.
**Reflection:**
In reflecting on this case, I agree with the decision to admit the patient due to the severity of her symptoms and potential risks associated with untreated mania. It’s crucial to address her acute symptoms, ensure safety, and stabilize her mood with appropriate medications. Learning from this case, I appreciate the importance of early recognition and intervention in manic episodes to prevent complications and promote recovery.
**References:**
1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.
2. Yatham, L. N., et al. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2), 97-170.
3. National Institute of Mental Health. (2021). Bipolar disorder. Retrieved from [https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml](https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml)
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This SOAP note template provides a structured approach to documenting the patient encounter, ensuring thorough assessment and planning for appropriate treatment and follow-up care. Adjustments can be made based on specific institutional guidelines or additional clinical findings.
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