640 SOAP Note NURS 632 SOAP Note Assignment
640 SOAP Note NURS 632 SOAP Note Assignment
You will be required to write two SOAP notes during the course. Both should address the management of an acute problem in an adult or older adult individual who has a chronic disease. For example, an acute onset of respiratory symptoms in a patient with diabetes. You could also address an acute exacerbation of a chronic problem. For example, a patient with chronic depression presents with an exacerbation or recurrence of depressive symptoms. Another example would be a patient with a history of chronic back pain s/p surgery presents with worsening pain and radicular symptoms.
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| Component | Criteria | Outcome Standard | Standard Met | Standard Partially Met | Omitted |
| “S” (subjective) | Introductory statement | Includes the chief complaint/reason for the encounter
Includes age, race, marital status, sex States reliability as a historian Comprises no more than the first 2 sentences of the note |
2 | 1 | 0 |
| HPI—if a new problem | Characterizes the chief complaint by location, quality, quantity, chronology, aggravating/ alleviating factors, associated manifestations, setting
Includes positives as well as pertinent negatives Includes PMH, FMH, SH,ROS, cultural or ethnic implications pertinent to the chief complaint Writes HPI in paragraph form (may list PMH, FMH, Meds, Allergies) |
2 | 1 | 0 | |
| HPI—if follow-up of a chronic problem | Summarizes course of illness—manifestations of illness, duration & progression, therapies (past and current), side effects, compliance, complications, impact on lifestyle, current status | 2 | 1 | 0 | |
| “O” (objective) | Physical Exam | Reflects attention to history; includes diagnostic studies done as part of the physical (e.g., in office EKG, urine, rapid strep) and that indicate reasonable diagnostic hypotheses | 2 | 1 | 0 |
| “A” (assessment) | Assessment | Identifies differential diagnosis which reflects thoughtful analysis of data | 2 | 1 | 0 |
| “P” (plan) | Plan | Includes: confirming or elaborating diagnostic studies that are not part of the exam; non-pharmacologic and pharmacologic treatment options; relevant patient education related to the disease process and treatment options (including potential complications); appropriate referrals if indicated; time frame and mechanism (phone? return visit?) for follow up
640 SOAP Note NURS 632 SOAP Note Assignment |
2 | 1 | 0 |
| Plan appropriate to diagnosis | Yes | No | |||
| Format | Only historical information is recorded under “S”
Only physical exam and results of diagnostic testing are recorded under “O” Actual diagnosis is recorded under “A” rather than just a summary of findings Uses proper medical terms Note is organized, concise |
2 | 1 | 0 | |