Description
Soap Note 2 Chronic Conditions
Soap Note 2 Chronic Conditions (15 Points) Due 7/13/2019
Pick any Chronic Disease from Weeks 6-10
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Late Assignment Policy
Assignments
turned in late will have 1 point taken off for every day assignment is late,
after 7 days assignment will get grade of 0. No exceptions
Follow the MRU Soap Note Rubric as a guide:
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: __________________________________
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Explanation & Answer
Attached.
Running head: SOAP NOTE: CROHN’S DISEASES
Soap Note: Crohn’s Diseases
Student’s Name:
Instructor’s Name:
Course:
Date:
1
SOAP NOTE: CROHN’ DISEASE
2
PATIENT INFORMATION
Name: Mrs. Foster
Age: 60 years
Sex: Female
Source: Patient
Allergies: None
Current medication: Citalopram and Aventyl HCI for depression
Immunization: Tdap Vaccine and Influenza vaccine in 2019 and Pneumococcal vaccine 2
years ago.
Surgical History:
Family History: Husband- Dead, 55 years old, Throat Cancer.
Father -Dead, 90 -year- old, Heart attack.
Mother- alive, 86 years Old, also suffers from Crohn’s disease and Blood pressure.
Two twin sons- Alive, 30 years old, Healthy
Social History: Heavy smoker, takes 4-5 cigarettes a day.
Social Celebrations: Retired and lives with his younger son.
SUBJECTIVE:
Chief Complain: Bowel obstructions, abdominal pain, and Anal Fixtures.
SOAP NOTE: CROHN’ DISEASE
3
Symptom analysis/ HPI: The 60-year-old female patient came in for a medical checkup about
three weeks ago. When he started experiencing Bowel obstructions accompanied by Anal fissures
leading to pain when going to the toilet, additionally, the patient complained of severe Diarrhea,
cramping, and abdominal pain from time to time.
The patient ha...