ST Thomas University Advanced FNP Clinical III SOAP Note

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opren2008

Health Medical

ST Thomas University

Description

SOAP Notes 2

SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
GDownload Graduate SOAP NOTE TEMPLATE.docx

For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:

S =Subjective data: Patient’s Chief Complaint (CC).O =Objective data: Including client behavior, physical assessment, vital signs, and meds.A =Assessment: Diagnosis of the patient's condition. Include differential diagnosis.P =Plan: Treatment, diagnostic testing, and follow up

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SOAP Note Template Encounter date: ________________________ Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____ Reason for Seeking Health Care: ______________________________________________ HPI:_________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________ Current perception of Health: Excellent Good Fair Poor Past Medical History • Major/Chronic Illnesses____________________________________________________ • Trauma/Injury ___________________________________________________________ • Hospitalizations __________________________________________________________ Past Surgical History___________________________________________________________ Medications: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Family History: ____________________________________________________________ Copyright © MVJ 2018 Social history: Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________ Employment Status: ______ Current/Previous occupation type: _________________ Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________ Sexual orientation: _______ Sexual Activity: ____ Contraception Use: ____________ Family Composition: Family/Mother/Father/Alone: _____________________________ Health Maintenance Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____ Exposures: Immunization HX: Review of Systems: General: HEENT: Neck: Lungs: Cardiovascular: Breast: GI: Male/female genital: Copyright © MVJ 2018 GU: Neuro: Musculoskeletal: Activity & Exercise: Psychosocial: Derm: Nutrition: Sleep/Rest: LMP: STI Hx: Physical Exam BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____ General: HEENT: Neck: Pulmonary: Cardiovascular: Breast: Copyright © MVJ 2018 GI: Male/female genital: GU: Neuro: Musculoskeletal: Derm: Psychosocial: Misc. Significant Data/Contributing Dx/Labs/Misc. Plan: Differential Diagnoses 1. 2. 3. Principal Diagnoses 1. Copyright © MVJ 2018 2. Plan Diagnosis Diagnostic Testing: Pharmacological Treatment: Education: Referrals: Follow-up: Anticipatory Guidance: Diagnosis Diagnostic Testing: Pharmacological Treatment: Education: Referrals: Follow-up: Anticipatory Guidance: Copyright © MVJ 2018 Signature (with appropriate credentials): __________________________________________ Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________ DEA#: 101010101 STU Clinic LIC# 10000000 Tel: (000) 555-1234 FAX: (000) 555-12222 Patient Name: (Initials)______________________________ Age ___________ Date: _______________ RX ______________________________________ SIG: Dispense: ___________ Refill: _________________ No Substitution Signature: ____________________________________________________________ Copyright © MVJ 2018 Copyright © MVJ 2018
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Explanation & Answer

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SOAP Note
Name of the student
Institutional affiliation
Date of submission

Copyright © MVJ 2018

SOAP Note
Encounter date: 15/09/2021
Patient Initials: J.K Gender: M/F/Transgender J.K Age: 52 years. Race: Latin American Ethnicity: Latin
Reason for Seeking Health Care: "I feel like an elephant is thumping in my chest. My feet and abdomen
have swollen, and I feel tired after walking over a short distance."
HPI: The above chief complaints started two months ago. The patient started experiencing chest
pains followed by shortness of breath that comes with palpitations. The chest pains are more
severe with activities such as walking and jogging. Chest pains are relieved with rest.
Allergies(Drug/Food/Latex/Environmental/Herbal): None.

Current perception of health: fair
Past Medical History
• Major/Chronic Illnesses: no history of chronic illness
• Trauma/Injury: head injury in 2016 after a road traffic accident
• Hospitalizations: admitted once in 2016 following a road traffic accident
Past Surgical History: craniotomy to drain the hematoma in 2016.
Medications: ceftriaxone drug for prophylaxis purposes. Furosemide to prevent water retention.
Phenytoin to prevent seizures. Magnesium sulfate prevents the increased stimulation of neurons.

Family History: Firstborn in a family of three children. Both siblings are alive and well. Mother
is alive and well, while the father died of hypertensive emergency in 2002. He is married with
one child. He lives with his wife and child.

Copyright © MVJ 2018

Social history:
Lives: Single-family House/Condo/ with stairs: Single-family house Marital Status:
married Employment Status: employed Current/Previous occupation type: teacher.
Exposure to: Smoke: Ye...


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