Using the attached SOAP note template, create one. Be creative, it has to be an adult patient this is the only requirement. Every other requirement is stated in the template. There is also attached a completed SOAP note from another student so you can see how its done. To do this paperwork you need to know how and what is a SOAp note.
SOAP notes are a standard method of documentation used by healthcare professionals to communicate patient information, track progress, and develop treatment plans. The acronym SOAP stands for Subjective, Objective, Assessment, and Plan. Each section of the SOAP note serves a specific purpose in organizing and presenting patient information in a structured format.
Subjective: The subjective section of a SOAP note includes information provided by the patient or their caregiver, as well as the healthcare professional’s observations and impressions. This section should include the patient’s chief complaint, present illness, medical history, symptoms, and any relevant information that the patient shares during the encounter.
Objective: The objective section of a SOAP note includes measurable and observable data obtained from the physical exam, diagnostic tests, and other objective assessments. This section should provide accurate and detailed information about the patient’s vital signs, physical findings, laboratory results, and any relevant information obtained from medical devices or imaging studies.
Assessment: The assessment section of a SOAP note includes the healthcare professional’s clinical impression and interpretation of the subjective and objective data. This section should include a concise summary of the patient’s condition, any diagnoses made or ruled out, and the healthcare professional’s analysis and interpretation of the data.
Plan: The plan section of a SOAP note outlines the healthcare professional’s proposed course of action for the patient. This section should include the recommended treatments, medications, diagnostic tests, referrals, follow-up appointments, and any other interventions or plans the healthcare professional deems appropriate.
Now, to create a SOAP note for an adult patient, we can fictionalize a scenario as an example:
Subjective:
Patient Name: John Smith
Age: 45
Chief Complaint: Abdominal pain
History of Present Illness:
John Smith presents today with complaint of severe abdominal pain that started 24 hours ago. He describes the pain as sharp and localized to the right lower quadrant. He denies any recent trauma, changes in bowel habits, vomiting, or fever. The pain is exacerbated by movement and deep palpation. He reports no previous episodes of similar pain. No alleviating factors have been identified.
Medical History:
John has a history of hypertension and hyperlipidemia. He is currently prescribed lisinopril and simvastatin. He is allergic to sulfa drugs, with no other known drug allergies. He denies any recent surgeries or hospitalizations.
Family History:
John reports a positive family history of colon cancer in his paternal grandfather.
Social History:
John is married and has two children. He works as a financial analyst and does not smoke. He drinks occasionally and denies any illicit drug use.
Objective:
Physical examination:
Vital Signs:
– Blood pressure: 130/80 mmHg
– Heart rate: 80 bpm
– Respiratory rate: 16 breaths per minute
– Temperature: 98.6°F
Abdominal Examination:
Inspection: Abdomen is slightly distended, no visible scars or skin changes. No hernias or masses are observed.
Palpation: Severe tenderness on palpation of the right lower quadrant. No rebound tenderness or guarding noted. Bowel sounds present and normal.
Percussion: No abnormal findings on percussion.
Auscultation: Normal bowel sounds auscultated in all four quadrants.
Assessment:
Based on the subjective and objective data, the assessment is as follows:
– Differential Diagnosis:
– Acute appendicitis
– Diverticulitis
– Gastroenteritis
– Ovarian cyst
– Kidney stone
Plan:
1. Order blood tests: complete blood count (CBC), comprehensive metabolic panel (CMP), and C-reactive protein (CRP).
2. Order an ultrasound of the abdomen to evaluate the appendix and any other potential causes of the abdominal pain.
3. Prescribe pain medication (if necessary) and provide instructions on when to seek emergency care if symptoms worsen.
4. Schedule a follow-up appointment in 48 hours to review test results and determine the next steps.
This fictionalized SOAP note demonstrates how subjective and objective information is combined to form an assessment and develop a plan for a patient with abdominal pain. The note provides a clear framework for communication and continuity of care. Please note that this example is for educational purposes only, and a qualified healthcare professional should be consulted for any real-life patient care.