Benign Prostatic Hyperplasia Soap Note Paper

Late Assignment Policy

Assignments turned in late will have 1 point taken off for every day assignment is late, after 7 days assignment will get grade of 0. No exceptions

  • Follow the MRU Soap Note Rubric as a guide
  • Use APA format and must include a minimum of 2 Scholarly Citations.
  • Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
  • Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated.

Please see College Handbook with reference to Academic Misconduct Statement.

The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.

  • I sent you the sample template.

Since all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

  1. Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.
  2. Subjective Data (___30pts.): This is the historical part of the note. It contains the following: a) Symptom analysis/HPI (Location, quality, quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations. (10pts). b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts). c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.
  3. Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate. a) b) c) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts). Pertinent positives and negatives must be documented for each relevant system.

Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

  1. Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.
  2. Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.
  3. Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.
  4. Clarity of the Write-up(___5pts.): Is it literate, organized and complete? Comments:

Total Score: ____________ Instructor: __________________________________ Guidelines for Focused SOAP Notes · Label each section of the SOAP note (each body part and system). ·

Do not use unnecessary words or complete sentences. · Use Standard Abbreviations S: SUBJECTIVE DATA (information the patient/caregiver tells you). Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis, physician-recommended return(s) for this patient visit.

The patient’s own words should be in quotes. History of present illness (HPI): a chronological description of the development of the patient’s chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLD CARTS), or an update on health status since the last patient encounter. Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-appropriate immunization status.

Family History (FH): Update significant medical information about the patient’s family (parents, siblings, and children). Include specific diseases related to problems identified in CC, HPI or ROS. Social History (SH): An age-appropriate review of significant activities that may include information such as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of education and sexual history.

Review of Systems (ROS). There are 14 systems for review. List positive findings and pertinent negatives in systems directly related to the systems identified in the CC and symptoms which have occurred since last visit;

  1. constitutional symptoms (e.g., fever, weight loss),
  2. eyes,
  3. ears, nose, mouth and throat,
  4. cardiovascular,
  5. respiratory,
  6. gastrointestinal,
  7. genitourinary,
  8. musculoskeletal,
  9. integument (skin and/or breast),
  10. neurological,
  11. psychiatric,
  12. endocrine,
  13. hematologic/lymphatic,
  14. allergic/immunologic.

The ROS should mirror the PE findings section. 0: OBJECTIVE DATA (information you observe, assessment findings, lab results). Sufficient physical exam should be performed to evaluate areas suggested by the history and patient’s progress since last visit. Document specific abnormal and relevant negative findings. Abnormal or unexpected findings should be described. You should include only the information which was provided in the case study, do not include additional data.

Record observations for the following systems if applicable to this patient encounter (there are 12 possible systems for examination): Constitutional (e.g., vital signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematologic/lymphatic/immunologic/lab testing. The focused PE should only include systems for which you have been given data. NOTE: Cardiovascular and Respiratory systems should be assessed on every patient regardless of the chief complaint.

Testing Results: Results of any diagnostic or lab testing ordered during that patient visit. A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code) List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.

Remember: Your subjective and objective data should support your diagnoses and your therapeutic plan. Do not write that a diagnosis is to be “ruled out” rather state the working definitions of each differential or primary diagnosis (es). For each diagnosis provide a cited rationale for choosing this diagnosis.

This rationale includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the focused PE findings and tests results that support the dx. Include the interpretation of all lab data given in the case study and explain how those results support your chosen diagnosis. P: PLAN (this is your treatment plan specific to this patient).

Each step of your plan must include an EBP citation. 1. Medications write out the prescription including dispensing information and provide EBP to support ordering each medication. Be sure to include both prescription and OTC medications. 2. Additional diagnostic tests include EBP citations to support ordering additional tests 3. Education this is part of the chart and should be brief, this is not a patient education sheet and needs to have a reference. 4.

Referrals include citations to support a referral 5. Follow up. Patient follow-up should be specified with time or circumstances of return. You must provide a reference for your decision on when to follow up. (Student Name) Miami Regional University Date of

Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. David Trabanco DNP, APRN,

AGNP-C, FNP-C Soap Note # Main Diagnosis (Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION Name: Mr. DT Age: 68-year-old Gender at Birth: Male Gender Identity: Male Source: Patient Allergies: PCN, Iodine Current Medications: • Atorvastatin tab 20 mg, 1-tab PO at bedtime • ASA 81 mg po daily • Multivitamin Centrum Silver PMH: Hypercholesterolemia Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.

Preventive Care: Colonoscopy 5 years ago (Negative) Surgical History: Appendectomy 47 years ago. Family History: Father- died 81 does not report information Mother-alive, 88 years old, Diabetes Mellitus, HTN Daughter-alive, 34 years old, healthy Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.

Sexual Orientation: Straight Nutrition History: Diets off and on, does not each seafood Subjective Data: Chief Complaint: “headaches” that started two weeks ago Symptom analysis/HPI: The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high

(159/100, 158/98 and 160/100 respectively)

Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting. Review of Systems (ROS) CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss.

NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures. HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing. RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis. CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal dyspnea.

GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or diarrhea. GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence. MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound. SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus. Objective Data: VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25.

Report pain 2/10. GENERAL APPEARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cones of light. Maxillary sinuses no tenderness.