Nursing Assignment

 Nursing Assignment

Instructions/Descriptions

Episodic/focused soap note template 2021 dr. K

Patient Information: Initials, Age, Sex, Race

SUBJECTIVE.

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 – or OLDCARTS.

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: Episodic/ Focused SOAP Note Template Format Essay Example.[Order Now]

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

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Please list in a bullet list, not a paragraph

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is i.e. angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

DO NOT LIST ALLERGIES IN TWO PLACES. POINTS TAKEN OFF FOR THIS. Nursing Assignment

PMHx: past major illnesses

PSH: and surgeries.

IMMUNIZATIONS: This is a separate item.

Depending on the CC, more info is sometimes needed. Do not state immunizations “up to date” for any age. This is usually never true and really unclear as to what this means.

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. This should be no more than one brief paragraph remember to include health promotion teaching and education for all patients, even if you are in a critical care setting. This is part of your grading rubric.

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. List in bullet points: I.E.[Order Now]

Mother: deceased age 79 MI

Father: alive & Well age 82

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. Use “denies” or “endorses”. Must be in interview format. You are interviewing the patient. Points taken off if the ROS sounds like a PE. Nursing Assignment

Note: if a body system is included in the CC and HPI – it must be included in the ROS and the PE. Please be mindful of this. It cannot be skipped if it is listed in the CC, HPI.

EXAMPLE OF COMPLETE ROS:

GENERAL: Orientation is often placed here. DO NOT PUT AA&O X3 OR 4. Points are taken off for this. For this course you must document what the patient is oriented to, i.e.:

Patient is alert and oriented to person, place, time and situation. (You do not need to put orientation in the PE in neuro unless you have not mentioned it elsewhere). The neuro PE should specify CN evaluation and Romberg -especially for stroke patients.

This 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. denies palpitations or edema. Nursing Assignment

RESPIRATORY: denies shortness of breath, cough or sputum. (or – endorses productive cough with specks of blood)

GASTROINTESTINAL: denies anorexia, nausea, vomiting or diarrhea. denies abdominal pain or bloody stools. Denies hematochezia

GENITOURINARY: complains of burning on urination. Denies pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL: denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. denies change in bowel or bladder control.

MUSCULOSKELETAL: denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC: denies anemia, or easy bruising.

LYMPHATICS: denies enlarged neck or armpit nodes. No history of splenectomy.

PSYCHIATRIC: Denies history of depression or anxiety. Denies suicidal ideations or attempts

ENDOCRINOLOGIC: denies reports of sweating, cold or heat intolerance. denies polyuria or polydipsia.

ALLERGIES: denies history of asthma, hives, eczema or rhinitis.

OBJECTIVE.

Start with vital signs: Temp, Pulse, Heart Rate, BP. O2 if acute care setting, weight and BMI mandatory. Nursing Assignment

It the heart rate is 99 and below – this is not tachy. If the heart rate is regular and 99 and below, this is NOT a “tachyarrhythmia”. Please grade murmurs if you identify one. Designate if your BMI is normal weight, overweight, obese, etc. This is important.

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.

IMPORTANT: Vital signs belong under PE not ROS. Do not put allergies on the soap note twice.

The neuro PE should evaluate the CN (list them – see the neuro exam doc in doc sharing)

The Muscle exam should note the muscle grading for each extremity starting at 5/5 to assess for weakness. If you are evaluating neuro and M/S together, title it that way. See form in doc sharing.

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 Format Essay Example.

Assessment.

DIFFERENTIAL DIAGNOSES (list a minimum of 3 differential diagnoses).

I highly recommend a pocketbook or app for differential diagnoses to help you with your soap notes.

Take your Geriatrics at Your Fingertips book with you to clinical.

I will post a list of DDx aps. In doc sharing. Please explore these as knowing DDx is very important and does take time to learn.

Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation of about one paragraph with evidence-based guidelines citations and references.

Recommend using your textbooks and required readings as your first go-to references.

REFERENCES

You are required to include at least three evidence-based peer-reviewed journal articles or evidenced based guidelines (but you can list as many as you wish) which relates to this case to support your diagnostics and differentials diagnoses.

You may use Up To Date once in a while but not as a general rule. Please use your textbook and required readings as your first choice for references. This will help you prepare for your knowledge checks.

Be sure to use correct APA 7th edition formatting. Journal articles or websites must be dated 5 years or sooner. Please use U.S. UK. Or Australian journal articles as a preference.

 Nursing Assignment

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