Week 7 SOAP Notes (please I need a good soap note) follow the rubric below 43 y/o female presents today for follow- up after ER visit at hospital
1. Hypertension- Patient states that on 3/25 was speaking at a conference at church and started to feel hot and lightheaded. The patient states sh went to the restroom and began to feel dizzy. The patient states she \”fell out\” and couldn\’t move, but was conscious. Patient states her BP was 130/90 when taken by the ambulance and 194/147 when she arrived to the hospital. Patient states her BP started to go down in the hospital when she was given IV fluids. The patient states that the night before she took 2-3 methyldopa pills because she forgot whether or not she took the earlier dose and states that the BP medication helps her sleep. Patient states she has been on methyldopa for 5 years and was put on it while trying to conceive a child. The patient states she would like to try another medication. Patient states Plan 1. Start Metoprolol 50mg oral tab; take 1 tab PO qam
2. Continue Methyldopa as prescribed.
3. Monitor the patient weekly until BP stabilizes; the goal is to eventually wean the patient off methyldopa.
4. RTC in 1 week for evaluation of treatment.
that she took a HCTZ in the past and it worked well but caused chest pains.
After completing this week’s Practicum Experience, select a patient whom you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:
• Subjective: What details did the patient provide regarding his or her personal and medical history?
• Objective: What observations did you make during the physical assessment?
• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
• Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies?
• Reflection notes: What would you do differently in a similar patient evaluation?
SOAP note rubric
Soap Note about 43 y/o female after ER visit at the hospital
Subjective (15 points)
• CC 1
• Pertinent positives (OLDCARTS) 5
• Pertinent negatives (from ROS) 5
• Pertinent PMH, SH, and FH 3
• Medications and drug/food allergies are not included 1
Objective (15 points)
• VS including BMI 2
• Heart and lungs 1
• Systems or specialty exam techniques that are not necessary to arrive at a diagnosis are included. -5
• Systems or specialty exam techniques that are necessary to arrive at your diagnosis are omitted. -5
• Diagnostic test results 2
Assessment – 10 points for each priority diagnosis (total 30 points)
Plan (15 points) ORDER NOW FOR A PLAGIARISM-FREE NURSING PAPER
• Medications discontinued (\”d/c lisinopril 10 mg daily”) 1
• Medications started (“start Avapro 150 mg daily”) 2
• Alternative therapies if appropriate (1 point) 1
• Health Promotion strategies – patient/family education 3
• Disease Prevention strategies with timeframe if appropriate 3
• Diagnostic tests ordered with timeframe (now, in 2 weeks, prior to f/u visit in 3 months) 3
• Referrals or consultations if appropriate 1
• Follow-up interval 1
Reflection notes (25 points)
• What did you learn from this experience? Any ah-ha’s? (5 points) 5
• What would you do differently? 5
• What additional data would you have gathered? 5
• What additional elements of the exam would you have done? 5
• Do you agree with your preceptor based on the evidence? 5