Episodic/Focused SOAP Note Template Assignment
Create an episodic/focused note in SOAP format about the case study below. Provide evidence from the literature to support diagnostic tests that would be appropriate for your case.
Continue documentation of focused/Episodic SOAP notes. In a Focus SOAP note, include an assessment of the General, Heart, Lungs, and Affected systems. In the Affected system, provide a detailed assessment based on what you expect to see, hear, and feel, based on your diagnosis. In completing your SOAP note, consider what history you need to gather from the patient. In the objective section, include findings from your Physical exam, based on the patient’s diagnosis. Refer to Chapter 2 of the Sullivan Text and the Episodic Template in Week 5 Learning Resources for Guidance. Episodic/Focused SOAP Note Template Assignment
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You will need to make up information to complete the focus note.
List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Case Study: Headaches
A 40-year-old female presents with a complaint of a headache for one week. Reports a “head cold” 3 weeks ago. Thought it was getting better, but sinus symptoms are back and even worse.
Describes the headache is located across her forehead; feels like pressure behind my eyes and unable to breathe out of nose. Also feels mucus running down the back of throat. Pain sometimes severe (8/10) but with acetaminophen reduces to moderate (4/10) and occasionally mild (2/10). Occasional nonproductive cough. Feels feverish at times; noted frequent sneezing and no appetite. Bending over seems to make the headache worse. “Acetaminophen improves my headache but doesn’t take it away.” Taking Sudafed HCL 120 mg every 12 hours, with some relief. Symptoms are worse in the morning – awakes with a headache. Ranges from 2/10 at its best to 8/10. Difficulty with concentrating at job and feels very tired.
The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. Episodic/Focused SOAP Note Template Assignment
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) 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 AA male). 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, Aleve makes it tolerable but not completely better Episodic/Focused SOAP Note Template Assignment
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs 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 Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Episodic/Focused SOAP Note Template Assignment
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
O.
Physical exam: 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. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines) Episodic/Focused SOAP Note Template Assignment
A.
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.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
You are required to include 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 to use correct APA 7th edition formatting. Episodic/Focused SOAP Note Template Assignment
