Comprehensive SOAP Note

I already did the first sections of soap note which are section l,ll, and lll which are attached so you can have an idea of what I need. now I need to finalize this and I’m having trouble doing it. I need from section IV from objective data all the way to the end. Comprehensive SOAP NoteThis Assignment will help develop skills to perform an integrated history and physical examination for individuals across the lifespan.Considerations of lifestyle practices, cultural/ethnic differences, and developmental variations will be incorporated into the plan of care.Use critical thinking and diagnostic reasoning skills to formulate differential diagnoses, medical diagnoses, and an evidence-based action plan.Include sections 1 and 2 of the SOAP note with recommendations (incorrect or omitted data) based on feedback provided for the previous sections of the SOAP note.Click here for the written guide for the Comprehensive SOAP Note.
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Running head: SOAP NOTE SECTION I WRITTEN GUIDE
Unit 2: SOAP Note Section I Written Guide
MN 552: Advanced Health Assessment and Diagnostic Reasoning
November 21, 2017
1
Running head: SOAP NOTE SECTION I WRITTEN GUIDE
2
SOAP Note Section I Written Guide
History, Interview, and Genogram Guide
Please select a volunteer friend or family member to interview and gather data to complete this
Assignment. The following guide will assist you in gathering subjective data in an organized,
systematic manner to prevent omission of important components of the health history. Please
remember to attach a Genogram with this Assignment as one document, if possible. You
may search the web to locate a suitable Genogram diagram to input data. Only include 3
generations in the genogram depiction.
Date of History/Interview: 11/19/2017
Source of history and Reliability: (client, family member, chart/record, etc.-sample on page 50 of
Jarvis textbook): Client, AAOX4.
1.
Biographical Data
a. Name: Jonna Pomales
b. Address: 808 Prime Terrace Miami, FL
c. Phone number: 852-9656-8696
d. Primary language: Spanish
e. Authorized representative: George Pomales
f. Age and Date of Birth: 42 years, January 7, 1975
g. Place of Birth: Puerto Rico
h. Gender: Female
i. Race: White
j. Marital Status: Married
k. Ethnic/Cultural Origin: Hispanic
l. Education (highest level completed): Doctor degree
m. Occupation/Professional: Lawyer
n. Health insurance: Cigna Health Insurance
2.
Chief Complaint (reason for seeking health care):
a. Brief spontaneous statement in client’s own words:
“I have been coughing and wheezing and sometimes I feel like something is
squeezing my chest. Sometimes I feel some shortness of breath”.
b. Includes when the problem started: “I have had colds before and flu but three weeks
ago when this problem started, it has not gone away. Also, I have been feeling a mild
pain in the chest cavity, but it comes and goes away”.
Running head: SOAP NOTE SECTION I WRITTEN GUIDE
3.
3
History of Present Illness: A well organized, chronological record of client’s reason for
seeking care, from time of onset to present. Please include the 8 critical characteristics using
the PQRSTU pneumonic.
P – Provocative or palliative (What brings it on? What makes it better or worse?):
“the pain comes and goes. I have such episodes mostly at night or when it is dusty”.
Q – Quality or quantity (Describe the character and location of the symptoms; How does
it look, feel, sound?):
“It feels like I am not getting enough air. Sometimes I feel like am going to faint but it
takes only a few minutes”.
R – Region or radiation (Where is it? Does the symptom radiate to other areas of the
body?):
“It does not spread to other parts of the body. It is mostly in my chest and nasal cavity”.
S – Severity (Ask the patient to quantify the symptom(s) on a scale of 0-10):
“7 at worst”.
T – Timing (Inquire about time of onset, duration, frequency, etc.):
“The first time I had the feeling, it was last spring, and I was walking in the fields with
my friend. All of a sudden, I felt an acute shortness of breath and tightness in my chest. I
stopped walking and lied on the ground and after five minutes the pain was gone. It has
happened twice since then”.
U – Understand Patient’s Perception of the problem (What do you think it means?)
The patient has allergic reaction to dust and pollen. She has shown symptoms of asthma
which are worsened by triggers such as dust, pollen, and mold. She has reported
wheezing and coughing especially at night. The first mild asthma attack was probably the
episode she described when walking last summer.
4.
Past Medical History
a. Medical Hx: major illnesses during life span, injuries, hospitalizations, transfusions,
and disabilities:
1. Hospitalizations: once after a road accident, recovered fully, blood transfusion
one unit of O+ .
2. Type I diabetes diagnosed 5 years ago, no major issues.
3. Hypertension which is controlled
Running head: SOAP NOTE SECTION I WRITTEN GUIDE
4
b. Childhood Illnesses: Measles, Chickenpox at age 12, mumps, rubella
c. Surgical Hx; procedures, dates, inpatient or outpatient
1. No surgical history
d. Obstetric HX: Number of pregnancies, term deliveries, preterm births, abortions
(spontaneous or induced), number of children living:
2 Pregnancies, 1 term vaginal delivery, spontaneous, 1 abortion, 1 son alive.
e. Immunizations:
Influenza vaccine: taken 5/7/2011
f. Psychiatric Hx: childhood and adult (treated or hx of):
Never treated for a Psych issue.
g. Allergies: Medications, food, inhalants or other (what occurs with reaction):
Allergic to dusty conditions and pollen, allergens trigger flu
h. Current Medications: Include all prescription, herbal/supplements and OTC, dosage,
frequency:
1. Diphenhydramine: 25mg to 50 mg PO every 4 to 6 hours as needed on an empty
stomach.
-Maximum dose 300mg in 24hrs.
2. Aspirin 81 mg PO daily in AM.
3. Metformin 500mg PO daily.
4. Lisinopril 10mg PO daily.
i. Last Examination Date: Physical, eye exam, foot exam, dental exam, hearing screen,
EKG, chest X-Ray, Pap test, mammogram, serum cholesterol, stool occult blood,
prostate, PSA, UA, TB skin test; other health maintenance tests for infants/children
may include sickle-cell, PKU, lead level, and hematocrit:
1. Last physical exam: 10/26/2017- NORMAL
2. Foot exam: 10/26/2017- NORMAL
3. Dental exam: 10/2017- NORMAL
4. Hearing screen: 10/26/2017- NORMAL
5. EKG: 10/26/2017- NORMAL
6. Chest X-Ray: 3/2017- NEGATIVE
7. Echo doppler: 3/2017- NEGATIVE
8. Pap test: 3/2017- NEGATIVE
9. Mammogram: 03/2017- NEGATIVE
Running head: SOAP NOTE SECTION I WRITTEN GUIDE
10. TB skin test (PPD): 03/2017- No Reactive
11. Cholesterol, Occult Blood, CBC, CMP and U/A: 6/10/2017- NORMAL
12. Bone density: 10/10/2017- NORMAL
5.
Family History (list FHx and design a genogram (computer)-include a key with the
genogram). The Genogram must include 3 generations.
a. Include parents, grandparents, spouse, and children.
b. Health conditions, familial and communicable diseases/illnesses
c. Note whether family member deceased or living
5
Running head: SOAP NOTE SECTION I WRITTEN GUIDE
Client: JP
Adrian
Age: 42
Alba
X
*
Date: 11/19/2017
c
M;3b
hj
Adriana
6
Franklin
X
#
X#
Jose
Jenna
*
Kristine
X
# *
George 48
JP 42 (Client)
#*
*
X
#
Jose JR
X
Crystal
#
*
Key:
Male
Johndy 15
Female X =deceased *= Hypertension
#= Diabetes
Running Head: SOAP Note Section II and III Written Guide
SOAP Note Section II and III Written Guide
Kaplan University
MN 552: Advanced Health Assessment and Diagnostic Reasoning
November 28, 2017
1
SOAP Note Section II and III Written Guide
2
MN552 Advanced Health Assessment
Unit 3 SOAP Note Section II and III Written Guide
1. Document appropriate data in the relevant body system.
a. Do not state “Negative, NA or Unremarkable” for any systems because the reader
will not know which questions were actually asked by the provider.
2. This is a comprehensive health history and should not contain physical exam findings.
The focused history data is relevant to the chief complaint and identified by pertinent
positive data documented during the health history.
3. Address each component of the SOAP note as noted in the written guide with relevant
data.
4. You may continue with the same volunteer to complete each section of the SOAP note.
II. Life style patterns
a.
b.
c.
d.
e.
f.
g.
h.
i.
Immigrant status – USA citizen/ was born in Puerto Rico.
Spiritual resources/religion – catholic
Health perception – Fine and working on health improvement by exercising.
Nutritional patterns: Appetite (any changes); satisfaction with current weight; gains or
losses; recall of usual intake; any cultural restrictions/intolerances; amount of fluid
per day and type – appetite has not changed, would like to remain stable on same
weight reason why diet that follows is based on 1500 calorie intake, drinks 8 bottles
of water and 1 sugar free juice daily.
Elimination patterns: Bowel (usual pattern and characteristics); bladder (usual pattern
and characteristics); any incontinence – Bowel movement are normal which consists
in 2 times a day, appearance is soft, and bladder output consists in 8-10 times a day it
depends on fluid intake, yellow clear in color and non-odorous.
Living environment: City, state; urban, rural, community; type of dwelling, facilities;
known exposures to environmental toxins – Kissimmee, FL; urban community which
is gated, one story house, built in 2015, environmental toxins are not recognized in
the zone.
Occupational health: Known exposure to environmental toxins at work – None
Functional assessment: ADLs, IADLs, interpersonal relationships/resources (see page
57 in Jarvis textbook) – No illnesses which allows patient to be Able to perform
ADLs and IADLs without help.
Role and family relationships: Immediate family composition; how are family
decisions made; impact of family member’s health on family – Composition of
Family is about 3 members, the patient, husband and son; Decisions are made based
on family needs and if is beneficial or not. The impact of patient health had been the
food menu adjustment due to patient’s health conditions.
3
SOAP Note Section II and III Written Guide
j. Cognitive function: Memory; speech; judgment; senses – Within normal limits No
memory loss or disorders, no confusion or mood changes, history of mental
dysfunction is none.
k. Rest/sleep patterns: Number of hours; naps; number of pillows; any aids for sleep –
Able to rest/sleep 8 hours a night, no naps are taken, uses 4 pillows and does not use
sleeping medication.
l. Exercise patterns: Type and frequency – 30 minutes of cardio 5 days a week during
the morning and 1 hour of weight lift at the gym 3 times a week.
m. Hobbies/recreation: Leisure activities; any travel outside of the US – Enjoys music,
visits Disney parks once a week, plays war games in her cellphone, Travels every 6
months to different states or countries as well 3 times a year to Puerto Rico.
n. Social habits: Tobacco; alcohol; street drug use – Had never use drugs or tobacco but
does drink wine socially.
o. Intimate partner violence (review screening questions on page 58 in the Jarvis
textbook) – Had never been exposed to violence by partner and feels safe at her home
and environment. No signs of abuse.
p. Coping/stress management: Any major life change in past 2 years; do you feel tense;
source; what helps – Recent life changes had been none, but yet job related stress and
able to manage it by talking with husband or coworkers.
q. Sexual patterns: Are you sexually active; gender preference; has anything changed
about your sexual health/function – Heterosexual preference, sexually active at the
time and follows up with gynecologist for yearly testing.
III. Review of Symptoms
Symptoms to Inquire About
(please see page 54–56 in Jarvis textbook)
Document pertinent
negatives and/or positives
The first system is addressed
to provide a guide
General
Wgt ?; weakness; fatigue; fevers
Pertinent negatives: Weight
gain none; no fatigue or
weaknesses and no fevers.
Skin
Rash; lumps; sores; itching; dryness; color
change; ? in hair/nails
Pertinent negatives: Skin
within normal limits, rash;
lumps; sores; itching; dryness
4
SOAP Note Section II and III Written Guide
none, no color change; No ?
in hair/nails.
Head
Headache; head injury; dizziness or vertigo
Pertinent negatives: Head
injuries none. No dizziness or
vertigo.
Pertinent positives:
Headaches
Eyes
Vision ?; eye pain, redness or swelling,
corrective lenses; last eye exam; excessive
tearing; double vision; blurred vision;
scotoma
Pertinent negatives: No
Vision ?; eye pain, redness or
swelling, excessive tearing;
double vision; blurred vision;
scotoma.
Pertinent positives:
corrective lenses; eye exam
August 2017- Myopia with
Astigmatism
Ears
Hearing ?; tinnitus; earaches; infections;
discharge, hearing loss, hearing aid use
Pertinent negatives: Hearing
?; tinnitus; earaches;
infections; discharge, hearing
loss, hearing aid use, none.
Nose/
Sinuses
Colds; congestion; nasal obstruction,
discharge; itching; hay fever or allergies;
nosebleeds; change in sense of smell; sinus
pain
Pertinent negatives: No nasal
obstruction, discharge; itching;
hay fever; nosebleeds; change
in sense of smell.
Pertinent positives: Colds,
congestion, sinus pain due to
seasonal allergies.
Throat/
Mouth
Bleeding gums; mouth pain, tooth ache,
lesions in mouth or tongue, dentures; last
dental exam; sore tongue; dry mouth; sore
throats; hoarse; tonsillectomy; altered taste
Pertinent negatives: No
Bleeding gums; mouth pain,
tooth ache, lesions in mouth or
tongue, dentures; sore tongue;
dry mouth; sore throats;
hoarse; tonsillectomy; altered
taste.
Pertinent positives: Normal
dental exam in June 2017.
5
SOAP Note Section II and III Written Guide
Neck
Lumps; enlarged or tender nodes, swollen
glands; goiter; pain; neck stiffness;
limitation of motion
Pertinent negatives: No
lumps; enlarged or tender
nodes, swollen glands; goiter;
pain; neck stiffness; limitation
of motion
Breasts
Lumps; pain; discomfort; nipple discharge,
rash, surgeries, history of breast disease;
performs self-breast exams and how often,
last mammogram; any tenderness, lumps,
swelling, or rash of axilla area
Pertinent negatives: Lumps;
pain; discomfort; nipple
discharge, rash, surgeries,
history of breast disease; any
tenderness, lumps, swelling, or
rash of axilla area, none.
Pertinent positives: Performs
self-breast exams every day.
Pulmonary
Cough — productive/non-productive;
hemoptysis; dyspnea; wheezing; pleuritic
pains; any H/O lung disease; toxin or
pollution exposure; last Chest x-ray, TB skin
test
Pertinent negatives: No
Cough — productive/nonproductive; hemoptysis;
dyspnea; wheezing; pleuritic
pains; any H/O lung disease;
toxin or pollution exposure;
Pertinent positives: Chest xray October 2017 was
negative; TB skin test August
2017- Non- Reactive
Cardiac
Chest pain or discomfort; palpitations;
dyspnea; orthopnea; edema, cyanosis,
nocturia; H/O murmurs, hypertension,
anemia, or CAD
Pertinent negatives: No
Chest pain or discomfort;
palpitations; dyspnea;
orthopnea; edema, cyanosis,
nocturia; H/O murmurs,
hypertension, anemia, or CAD
Pertinent positives: H/O
Hypertension.
G/I
Appetite ?; jaundice; nausea/emesis;
dysphagia; heartburn; pain;
belching/flatulence; ? in bowel habits;
hematochezia; melena; hemorrhoids;
constipation; diarrhea; food intolerance
Pertinent negatives: No
Appetite ?; jaundice; emesis;
dysphagia; pain; ? in bowel
habits; hematochezia; melena;
hemorrhoids; constipation;
diarrhea; food intolerance.
6
SOAP Note Section II and III Written Guide
GU
Frequency; nocturia; urgency; dysuria;
hematuria; incontinence
Pertinent negatives: No use
of Kegel exercises after
childbirth; use of birth control
Females: Use of Kegel exercises after
methods; HIV exposure;
childbirth; use of birth control methods; HIV Menarche; dysmenorrhea;
exposure; Menarche; frequency/duration of
PMS symptoms: bleeding
menses; dysmenorrhea; PMS symptoms:
between menses or after
bleeding between menses or after
intercourse; LMP; vaginal
intercourse; LMP; vaginal discharge;
discharge.
itching; sores; lumps; menopause; hot
flashes; post-menopausal bleeding;
Pertinent positives: Monthly
normal menses that lasts for 6
Males: Caliber of urinary stream; hesitancy; days.
dribbling; hernia, sexual habits, interest,
function, satisfaction; discharge from or
sores on penis; HIV exposure; testicular
pain/masses; testicular exam and how often
Peripheral
Vascular
Claudication; coldness, tingling, and
numbness; leg cramps; varicose veins; H/O
blood clots, discoloration of hands, ulcers
Pertinent negatives: No
claudication; coldness,
tingling, and numbness; leg
cramps; varicose veins; H/O
blood clots, discoloration of
hands, ulcers.
Musculoskeletal
Muscle or joint pain or cramps; joint
stiffness; H/O arthritis or Gout; limitation of
movement; H/O disk disease
Pertinent negatives: No joint
pain or cramps; joint stiffness;
H/O arthritis or Gout;
limitation of movement; H/O
disk disease
Pertinent positives: Muscle
pain due to weight lift.
Neuro
Syncope; seizures; weakness; paralysis;
stroke, numbness/tingling; tremors or tics;
involuntary movements; coordination
problems; memory disorder or mood
change; H/O mental disorders or
hallucinations
Pertinent negatives: No
Syncope; seizures; weakness;
paralysis; stroke,
numbness/tingling; tremors or
tics; involuntary movements;
coordination problems;
memory disorder or mood
change; H/O mental disorders
or hallucinations
Heme
Hx of anemia; easy bruising or bleeding;
blood transfusions or reactions; lymph node
Pertinent negatives: No Hx
of anemia; easy bruising or
7
SOAP Note Section II and III Written Guide
swelling; exposure to toxic agents or
radiation
bleeding; lymph node
swelling; exposure to toxic
agents or radiation
Pertinent positives: Blood
transfusion once in December
2015, no reactions.
Endo
Heat or cold intolerance; excessive
sweating; polydipsia; polyphagia; polyuria;
glove or shoe size; H/O diabetes, thyroid
disease; hormone replacement; abnormal
hair distribution
Pertinent negatives: No heat
or cold intolerance; excessive
sweating; polydipsia;
polyphagia; polyuria; glove or
shoe size; thyroid disease;
hormone replacement;
abnormal hair distribution
Pertinent positives: H/O
diabetes.
Psych
Nervousness/anxiety; depression; memory
changes; suicide attempts; H/O mental
illnesses
Pertinent negatives: No
Nervousness/anxiety;
depression; memory changes;
suicide attempts; H/O mental
illnesses
SOAP Note Section II and III Written Guide
8
Reference
Jarvis, C. (2016). Physical examination and health assessment (7th ed.). St, Louis MO: Elsevier.
MN552 Advanced Health Assessment
Comprehensive SOAP Note Written Guide
This guide will assist you to document history data and perform a comprehensive physical exam
in an organized and systematic manner. Please include a heart exam and lung exam on all clients
regardless of the reason for seeking care. So, if someone presented with cough and cold
symptoms, you would examine the general appearance, HEENT, neck, heart, and lungs for a
focused/episodic exam. However, this Assignment requires assessment of all body systems. The
pertinent positive findings should be relevant to the chief complaint and health history data.
Please follow the guide and include all previous sections of the SOAP note with corrections
based on feedback, as well as the Objective and Plan sections.
I. Subjective data
Date of History/Interview:
Source of history and Reliability: (client, family member, chart/record, etc.-sample on page 50 of
Jarvis textbook)
1.
Biographical Data
a. Name (use initials only)
b. Address
c. Phone number
d. Primary language
e. Authorized representative
f. Age and Date of Birth
g. Place of Birth
h. Gender
i. Race
j. Marital Status
k. Ethnic/Cultural Origin
l. Education ( highest level completed)
m. Occupation/Professional
n. Health insurance
2.
Chief Complaint (reason for seeking health care):
a. Brief spontaneous statement in client’s own words
b. Includes when the problem started ( “chest pain for 2 hours”)
3.
History of Present Illness: A well organized, chronological record of client’s reason for
seeking care, from time of onset to present. Please include the 8 critical characteristics using
the PQRSTU pneumonic.
P – Provocative or palliative (What brings it on? What makes it better or worse?)
Q – Quality or quantity (Describe the character and location of the symptoms; How does
it look, feel, sound?)
R – Region or radiation (Where is it? Does the symptom radiate to other areas of the
body?).
S – Severity (Ask the patient to quantify the symptom(s) on a scale of 0-10).
T – Timing (Inquire about time of onset, duration, frequency, etc.)
U – Und …
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