CREATE THE SOP NOTE USING THE GUIDE AND PATIENT INFORMATION
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Miami Regional University |
| Case ID #: 2844-20220119-004 (Status: NOT Approved) |
Date of Service: |
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Student Information – Santiesteban Molina, Osmel |
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Semester: |
Spring |
| Course: |
MSN6150C Advanced Practice Pediatrics |
| Preceptor: |
TREJO, RODOLFO |
| Clinical Site: |
Neighborhood Family Doctor.Atlantis |
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Setting Type: |
Underserved area/population |
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Patient Demographics |
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10 years |
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Race: |
Hispanic |
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Gender: |
Female |
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Insurance: |
Medicare |
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Referral: |
No referral |
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Clinical Information |
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15 minutes |
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5 minutes |
| Type of Decision-Making: |
Straightforward |
| Reason for Visit: |
Follow-up (Routine) |
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Chief Complaint: |
“I have cough and general malaise” |
| Type of HP: |
Problem Focused |
| Social Problems Addressed: |
Safety Growth & Development Prevention Education/Language Nutrition/Exercise |
| Procedures/Skills (Observed/Assisted/Performed) | |
| ICD-10 Diagnosis Codes | |
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#1 – |
J00 – ACUTE NASOPHARYNGITIS [COMMON COLD] |
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CPT Billing Codes |
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#1 – |
99212 – OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; STRTFWD MED DECISION; 10-19 MIN |
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Birth & Delivery |
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Medications |
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# OTC Drugs taken regularly: |
0 |
| # Prescriptions currently prescribed: |
0 |
| # New/Refilled Prescriptions This Visit: |
3 |
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Types of New/Refilled Prescriptions This Visit: Analgesic/Antipyretic – Acetaminophen combinations ENT – Decongestants/antihistamine combinations ENT – Expectorants |
Adherence Issues with Medications:
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Other Questions About This Case |
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| Patient’s Primary Language: |
Spanish |
| Smoking Assessment: |
Never |
| Advanced Directive: |
No |
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Packs per day: |
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Clinical Notes |
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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).
4) Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.
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.
(Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C
Soap Note
PATIENT INFORMATION
Name: Mrs
Age: 32 years old
Gender at Birth: Female
Gender Identity: Female
Source: Patient
Allergies:
NKDA
Subjective Data
Chief Complaint (CC)
The affected person communicates issues approximately her right eye. She reviews having a tingling and eating sensation in his proper eye. Also, She says that the attention creates greater fluid than expected, and the affected person frequently awakens with a dried up eyelid.
History of Present Illness (HPI)
The affected person is femmale. She is 32 years of age. The affected person wears touch focal factors because of having nearsightedness. Nonetheless, there may be no acknowledged records of her having a few different illnesses related to eyesight problems. The precept grievances of the affected person comprise redness and inflammation of the conjunctiva of the proper eye, accelerated tear advent and presence of fluid launch in the attention. Besides, she reviews to having problems with carrying his touch focal factors. The proper eye started out to tingle and eat 3 days prior. The affected person tried to smooth the attention with water and searched for any unexpected articles which could have brought about the bothering. Then, at that point, the affected person carried out Visine eye drops, which in brief mitigated the aggravation. Be that because it may, the redness did not disappear. The left eye seems to appearance sound. The affected person reviews to having notable cleanliness and says that she washes palms mechanically.
Allergies
NKDA
Past Medical History
The affected person became decided to have nearsightedness while he became twelve years of age. She normally wore glasses. Nonetheless, she selected to extrude to touch focal factors a month prior. The affected person has no set of reviews of various illnesses related to eyesight. No beyond records of eye illnesses is recorded.
Family History
The affected person denies having any own circle of relative’s ancestry pertinent to his condition. The dad has a beyond packed with controlled high blood pressure. She takes meds and plays mechanically check-u.s. the clinical clinic. The mom has a historical past marked via way of means of a summed up anxiety problem, that’s being dealt with treatment. She became decided to have GAD a 12 months prior. No scientific records recognized with eye infections may be found.
Surgery
The affected person has no set of reviews of considerable clinical processes.
Social History
The affected person confesses to smoking and ingesting on unusual events. She denies illegal remedy use. The affected person lives together along with his higher 1/2 of and girl. She fills in as an educator at a college. She denies having distressing encounters at work. She would not exercise continually due to a bustling timetable. His well-being degree is regular. Be that because it may, the historic backdrop of high blood pressure and mental maladjustment in his own circle of relatives need to be taken into consideration later on.
Current Medications
The affected person denies taking any meds.
Review of Systems (ROS): The affected person denies having any new frame problems or weight extrude. He has a regular starvation and rests now no longer surprisingly. The ranges of power are everyday also.
Cardiovascular: The affected person denies any chest torments, palpitations, edema, or dyspnea.
Respiratory: The affected person reviews typically approving of relaxing. He denies bronchial allergies or hacking.
Dermatology: The affected person denies having any pores and skin problems. Notwithstanding, he reviews to having redness and bothering across the proper eye, confessing to contacting and scouring it previously, then after the truth the presence of facet results. Generally speaking, she denies any scaling, knots, or rankles. Mouth, throat, nose, ears: The affected person denies having a touchy throat, oral or dental problems, nasal clog, or listening to misfortune.
Eyes: The affected person confesses to having nearsightedness, which he did not enterprise to restore with any clinical processes or meds. As according to the affected person, the left eye isn’t always dry or bothered. The proper eye is pink and bothersome. The affected person moreover reviews to having obscured imaginative and prescient in his proper eye due to over the pinnacle tear advent and launch. The hassle centering is clarified via way of means of nearsightedness, the character of sight isn’t always basically unique.
Genitourinary: The affected person denies any progressions in criticalness. There isn’t anyt any aggravation all through pee.
Gastrointestinal: The affected person denies having illness or lack of starvation. She denies having any belly torments.
Outer muscle: The affected person denies joint agony, muscle torment, squeezing, firmness, or expanding.
Hematologic: The affected person denies pallor or unusual dying.
Neurologic: The affected person denies cerebral pains, sluggishness, wooziness, cognitive decline, shortcoming, seizures, or deadness.
Unfavorably susceptible: The affected person denies having occasional sensitivities, meals hypersensitivities, or creature sensitivities. There isn’t any own circle of relatives historical past of sensitivities too.
Mental: The affected person denies misery, self-adverse contemplations, a snoozing disorder, or anxiety. She denies having nonstop apprehension or stress.
Objective Data
Vital Signs/Height/Weight Stature: five’8″ Weight: one hundred fifty lb Temperature: 98.five F
Heartbeat: seventy four BPM BP: 117/73
General Appearance
The affected person is a stable searching female and not using a obtrusive clinical problems. She would not look like in hassle. The affected person is obvious and compact in her discourse. She sees all inquiries and solutions them with subsequent to no problems. Cardiovascular: Heartbeat is every day with regular charge and beat. No jogs, mumbles, snaps, or rubs present. There isn’t any edema, cyanosis, or clubbing.
Respiratory: The affected person’s lungs are clear, there aren’t any sounds. The respiratory is even and has no obstacles.
Stomach: Abdomen is non-sensitive and sensitive. Entrails sounds are to be had. There isn’t any tracking and no masses.
Skin: The affected person’s pores and skin is dry and warm. There aren’t any ulcers, wounds, or accidents apparent. The pores and skin of the proper eyelid is marginally red and aggravated. There isn’t any considerable inflammation of the eyelid.
Mouth/Throat: Membranes aren’t dry. The pharynx is every day. The oropharynx is clear. Eyes: The conjunctiva of the proper eye is pink. Fluid watery launch is to be had with inside the excited eye. Understudies are equal and receptive to light. The affected person would not seem to have any similarly disintegration in eyesight. Red reflex is to be had respectively. There isn’t any strabismus or nystagmus present. The fundoscopic check is typical.
Assessment
Differential Diagnosis
Subconjunctival Hemorrhage. As indicated via way of means of Mayo Clinic (2017), the subconjunctival drain is a breaking of a vein with inside the conjunctiva of an eye. This problem introduces itself as a pink conjunctiva. This form of drain can occur in view of various motives like a stable wheeze of a hack. Be that because it may, this problem wears bring forth any important harm to the individual’s eye it typically disappears in numerous days. The affected person’s eye appears pink. Notwithstanding, distinctive facet results that the affected person encounters aren’t basically related to this problem. Subconjunctival discharge isn’t always joined via way of means of inflammation or aggravation. Moreover, the redness of the attention resulting from this affected person isn’t always similar to redness skilled via way of means of people with discharge. Accordingly, this end may be precluded.
Blepharitis. Blepharitis is the inflammation of the eyelid. The manifestations of this contamination comprise redness and disturbance of the eyelid, redness of the attention, swollen eyes, furthermore, inordinate tearing (National Eye Institute, 2017). Also, blepharitis is frequently trailed by crusting of the eyelashes, obscured vision, and foamy tears. Blepharitis is generally brought about by microscopic organisms or skin sicknesses, for example, skin break out and scalp dandruff. A large number of the manifestations of this illness line up with issues of the patient. Be that as it may, while his eye is red and aggravated, his eyelid isn’t altogether aroused. Additionally, the hardness of the eyelashes is generally probable brought about by over the top tearing, which isn’t foamy. Blepharitis can be precluded on account of the eyelid’s condition.
Conjunctivitis. Conjunctivitis, in any case called pink eye, is viewed as the most well-known eye contamination (Centers for Disease Control and Prevention, 2017). It can happen because of various reasons, including hypersensitive responses, microscopic organisms, respiratory diseases, and awful cleanliness. A wide range of conjunctivitis are described by redness and irritation of the eye, extreme tear creation, and release. Nonetheless, a few indications are unique. Hypersensitive conjunctivitis happens occasionally and is frequently trailed by different sorts of unfavorably susceptible responses like roughage fever and asthma. Viral conjunctivitis generally goes with a typical virus. At last, bacterial conjunctivitis frequently happens along with different contaminations. Moreover, ill-advised hand washing can cause conjunctivitis also. Contact focal points may likewise disturb the eye in case they are not put away or dealt with appropriately.
Medical Diagnosis
The launch withinside the affected person’s eye is not thick or foamy, which precludes bacterial conjunctivitis. The affected person denies having any sicknesses or hypersensitive responses. Nonetheless, he confesses to carrying touch focal factors, which he acquired alternatively as of late. Accordingly, it’s far covered to simply accept that the aggravation of the proper eye is introduced approximately with the aid of using beside the point focal factor care. It is potential that the affected person unnoticed to easy the touch focal factors accurately, which introduced approximately the aggravation of the proper eye. Along those lines, the realization of conjunctivitis may be affirmed.
Plan
Orders
Most kinds of conjunctivitis don’t need extra treatment (Azari and Barney, 2013). In any case, to alleviate the aggravation, the patient should keep on utilizing Visine eye drops and stick to a stricter handwashing schedule. Additionally, the patient should change contact focal points and think about buying an alternate brand of focal point arrangement.
Education
Furnish with nourishment/dietary data.
Daily circulatory strain checking log at home double a day for 7 days, keep a record, bring the record on the following encounter with her PCP
Instruction about drug consumption consistence.
Education of potential complexities like stroke, respiratory failure, and different issues.
Patient was instructed on course of hypertension, just as notice signs and side effects, which could show the need to go to the E.R/U.C. Addressed all pt. questions/concerns. Pt expresses comprehension to all
Follow-Up Plans
The following arrangement is essential if the patient keeps on encountering disturbance in his right eye. For this situation, the following gathering ought to incorporate extra tests and adhere to up directions. On the off chance that the issue doesn’t disappear, the patient can take anti-microbials to stop the irritation.
References
Azari, A. A., & Barney, N. P. (2013). Conjunctivitis: A systematic review of diagnosis and treatment. Jama, 310(16), 1721-1730.
Centers for Disease Control and Prevention. (2017). Conjunctivitis. Retrieved from https://
www.cdc.gov/conjunctivitis/index.html
Mayo Clinic. (2017). Subconjunctival hemorrhage. Retrieved from
http://www.mayoclinic.org/diseases-conditions/subconjunctival-
hemorrhage/home/ovc-20231436
National Eye Institute. (2017). Facts about blepharitis. Retrieved from https://nei.nih.gov/health/blepharitis/blepharitis
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