Posted: August 15th, 2023

SOAP Note Template

SOAP Note Template

Subjective – The “history” section

HPI: include symptom dimensions, chronological narrative of patient’s complains, information obtained from other sources (always identify source if not the patient, Could be from patient, family member, paramedics) If patient unconscious cannot get info from them.

Pertinent past medical history. If available.

Current medications (list with daily dosages).

Objective – The physical exam and laboratory data section

Vital signs including oxygen saturation when indicated.

Focuses physical exam.

All pertinent labs, x-rays, etc. completed at the visit.

Assessment/Problem List – Your assessment of the patient’s problems

Assessment: A one sentence description of the patient and major problem

Problem list: A numerical list of problems identified

All listed problems need to be supported by findings in subjective and objective areas above. Try to take the assessment of the major problem to the highest level of diagnosis that you can, for example, “low back sprain caused by radiculitis involving left 5th LS nerve root.”
Look up ICD 10 codes for Dx. This is a good link – https://www.icd10data.com/search?s=hypertension
Try not to overthink this aspect – as it becomes overwhelming very quickly.

Plan – Your plan for the patient based on the problems you’ve identified

Develop a diagnostic and treatment plan for each differential diagnosis.

Your diagnostic plan may include tests, procedures, other laboratory studies, consultations, etc.

Your treatment plan should include: patient education, pharmacotherapy if any, other therapeutic procedures. You must also address plans for follow-up (next scheduled visit, etc.).

Try to keep this simple.
In order to write a case study paper, you must carefully address a number of sections in a specific order with specific information contained in each. The guideline below outlines each of those sections.

Section

Information to Include

Introduction (patient and problem)

Explain who the patient is (Age, gender, etc.)
Explain what the problem is (What was he/she diagnosed with, or what happened?)
Introduce your main argument (What should you as a nurse focus on or do?)
Pathophysiology

Explain the disease (What are the symptoms? What causes it?)
History

Explain what health problems the patient has (Has she/he been diagnosed with other diseases?)
Detail any and all previous treatments (Has she/he had any prior surgeries or is he/she on medication?)
Nursing Physical Assessment

List all the patient’s health stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.)
Related Treatments

Explain what treatments the patient is receiving because of his/her disease
Nursing Diagnosis & Patient Goal

Explain what your nursing diagnosis is (What is the main problem for this patient? What need to be addressed?)
Explain what your goal is for helping the patient recover (What do you want to change for the patient?)
Nursing Interventions

Explain how you will accomplish your nursing goals, and support this with citations (Reference the literature)
Evaluation

Explain how effective the nursing intervention was (What happened after your nursing intervention? Did the patient get better?)
Recommendations

Explain what the patient or nurse should do in the future to continue recovery/improvement
Your paper should be 3-4 pages in length and will be graded on how well you complete each of the above sections. You will also be graded on your use of APA style and on your application of nursing journals into the treatments and interventions. For integrating nursing journals, remember the following:

Make sure to integrate citations into all of your paper
Support all claims of what the disease is, why it occurs and how to treat it with references to the literature on this disease
Always use citations for information that you learned from a book or article; if you do not cite it, you are telling your reader that YOU discovered that information (how to treat the disease, etc.)
Review the rubric for specific grading criteria.

Points possible: 65

Rubric
General Education Standardized Rubric: PATH 370 Signature Assignment

General Education Standardized Rubric: PATH 370 Signature Assignment

Criteria Ratings Pts
This criterion is linked to a Learning OutcomeIntroduction

3.5 to >3.12 pts
Exceeds Expectations

Introduction summarizes the case comprehensively and prepares the reader for the remainder of the paper.

3.12 to >2.52 pts
Meets Expectations

Introduction summarizes the case and somewhat prepares the reader for the remainder of the paper.

2.52 to >2.07 pts
Approaches Expectations

Introduction lacks detail to prepare the reader for the case.

2.07 to >0 pts
Does Not Meet Expectations

Introduction is not present or is grossly erroneous.

3.5 pts

This criterion is linked to a Learning OutcomePathophysiology

8.1 to >7.21 pts
Exceeds Expectations

Identifies and thoroughly explains the pathogenesis of the disease topic. Information is scientifically sound, thorough, supported and sufficient.

7.21 to >5.83 pts
Meets Expectations

Mostly Identifies and thoroughly explains the pathogenesis of the disease topic. Information is scientifically sound, thorough, necessary and sufficient.

5.83 to >4.78 pts
Approaches Expectations

Provides insufficient explanations. Information is not entirely scientifically sound, necessary or supported with evidence and a sound rationale.

4.78 to >0 pts
Does Not Meet Expectations

Does not answer or answers incorrectly with insufficient explanations. Information is not scientifically sound, necessary or sufficient.

8.1 pts

This criterion is linked to a Learning OutcomeHistory, Physical and Related Treatments

8.4 to >7.48 pts
Exceeds Expectations

Provides a detailed patient history, physical assessment findings, treatment, and related treatments for the disease topic. Information is scientifically sound, thorough, supported and sufficient.

7.48 to >6.05 pts
Meets Expectations

Provides most patient history, physical assessment findings, treatment, and related treatments for the disease topic. but may be limited. Information is mostly scientifically sound, thorough, necessary and sufficient.

6.05 to >4.96 pts
Approaches Expectations

Provides insufficient explanations. Information is not entirely scientifically sound, necessary or supported with evidence and a sound rationale.

4.96 to >0 pts
Does Not Meet Expectations

Does not answer or answers incorrectly with insufficient explanations. Information is not scientifically sound, necessary or sufficient.

8.4 pts

This criterion is linked to a Learning OutcomeNursing Diagnosis and Patient Goals

8.1 to >7.21 pts
Exceeds Expectations

Provides thorough and detailed nursing diagnosis and patient goal. Information is scientifically sound, supported and sufficient.

7.21 to >5.83 pts
Meets Expectations

Provides mostly detailed nursing diagnosis and patient goal. Information is mostly scientifically sound, support and sufficient.

5.83 to >4.78 pts
Approaches Expectations

Provides insufficient explanations. Information is not entirely scientifically sound, necessary and sufficient. Does not address the context sufficiently or with sound rationale.

4.78 to >0 pts
Does Not Meet Expectations

Does not answer or incorrectly explains content.Information is not scientifically sound, necessary or sufficient

8.1 pts

This criterion is linked to a Learning OutcomeNursing Interventions

8.1 to >7.21 pts
Exceeds Expectations

Thoroughly details the nursing interventions. Detailed explanation of nursing goals.Rationale is thorough, supported and sufficient.

7.21 to >5.83 pts
Meets Expectations

Provides some details of the nursing interventions. Detailed explanation of nursing goals.Rationale is supported and mostly sufficient.

5.83 to >4.78 pts
Approaches Expectations

Provides insufficient explanations. Information is not entirely scientifically sound, necessary and sufficient. Does not address the context sufficiently or with sound rationale.

4.78 to >0 pts
Does Not Meet Expectations

Does not answer or answers incorrectly with insufficient explanations. Information is not scientifically sound, necessary or sufficient.

8.1 pts

This criterion is linked to a Learning OutcomeEvaluation

8.1 to >7.21 pts
Exceeds Expectations

Provides thorough and insightful explanation of the effectiveness of the nursing intervention. Information is scientifically sound, supported andsufficient in detail

7.21 to >5.83 pts
Meets Expectations

Provides most thorough and insightful explanation of the effectiveness of the nursing intervention. Information is mostly scientifically sound, supported but may lack detail in some areas.

5.83 to >4.78 pts
Approaches Expectations

Provides insufficient explanations of the effectiveness of the nursing interventions. Does not address the context sufficiently or with sound rationale.

4.78 to >0 pts
Does Not Meet Expectations

Does not answer or answers incorrectly with insufficient explanations. Information is not scientifically sound, necessary or sufficient.

8.1 pts

This criterion is linked to a Learning OutcomeRecommendations

8.1 to >7.21 pts
Exceeds Expectations

Provides an overall thorough explanation of patient recommendations.Clinical findings are supported with evidence, compared and rationalized thoroughly. Recommendations for continued recovery/improvement explained and supported.

7.21 to >5.83 pts
Meets Expectations

Provides an overall thorough explanation of patient recommendations.Some clinical findings are supported with evidence, compared and rationalized thoroughly. Recommendations for continued recovery/improvement explained and supported.

5.83 to >4.78 pts
Approaches Expectations

Provides insufficient explanations. Information is not entirely scientifically sound, necessary and sufficient. Does not address the context sufficiently or with sound rationale

4.78 to >0 pts
Does Not Meet Expectations

Does not answer or answers incorrectly with insufficient explanations. Information is not scientifically sound, necessary or sufficient.

8.1 pts

This criterion is linked to a Learning OutcomeAPA format and References

7 to >6.23 pts
Exceeds Expectations

Meets all the requirements related to length. There is a minimum of 3 scholarly resources with at least 1 non-internet source. All references are correctly cited in APA format. The student shows a solid grasp of APA formatting, paraphrasing and citations.

6.23 to >5.04 pts
Meets Expectations

Meets most of the requirements related to length. There is a minimum of 3 resources with at least 1 non-internet source; the references may be questionable or not scholarly in nature. Most references are correctly cited in APA format. The student shows a good grasp of APA formatting, paraphrasing and citations but needs refinement in some areas.

5.04 to >4.13 pts
Approaches Expectations

Meets some of the requirements related to length but is lacking enough to impede the meaning of the paper. The references do not meet required count and/or may be questionable or not scholarly in nature. References are not correctly cited in APA format. The student does not show a good grasp of APA formatting, paraphrasing and citations.

4.13 to >0 pts
Does Not Meet Expectations

Does not follow format, length and layout requirements. References are not present or do not support scholarly intention. A lack of effort it apparent. There are extensive errors in formatting.

7 pts

This criterion is linked to a Learning OutcomeMechanics

5.6 to >4.98 pts
Exceeds Expectations

Answers are well written throughout. Information is well organized and clearly communicated.The writing is free of spelling and grammatical errors.

4.98 to >4.03 pts
Meets Expectations

Answers are well written throughout and the information is reasonably organized and communicated. It is mostly free of spelling and grammatical errors.

4.03 to >3.3 pts
Approaches Expectations

Answers are somewhat organized and lacks some clarity. Contains some spelling and grammatical errors

3.3 to >0 pts
Does Not Meet Expectations

Answers are not well written and the information is poorly organized and lacks clarity. It contains many spelling and grammatical errors

5.6 pts

Total Points: 65

Hello Everyone,

Use this for your signature assignment.

You must create a patient. History of current condition, prior medical conditions. Basically it is an intake.

Use this for your SOAP note form.

SOAP Note TemplateDownload SOAP Note Template

You must include a short paragraph after the SOAP note, in this paragraph you will be explaining to the patient what happened, what are the treatments, and what happens if the patient does not comply.

Do this in your own words, simple to the point, and most importantly compassionate

.Per instructor we should not choose simple diseases like UTI and go with something more. complicated

_______________________________________________-
SOAP Note Template

Subjective – History Section

History of Present Illness (HPI): The patient presents with a comprehensive account of symptoms, detailing the dimensions of discomfort and the chronological progression of complaints. Information from secondary sources such as family members or paramedics is included, always attributing the source. In cases of unconscious patients, data retrieval is challenging.

Pertinent Past Medical History: The patient’s medical background, including any relevant conditions, treatments, or surgeries, is documented.

Current Medications: A list of the patient’s medications along with their daily dosages is provided.

Objective – Physical Exam and Laboratory Data

Vital Signs: The patient’s vital signs, including oxygen saturation when indicated, are recorded.

Focused Physical Exam: A targeted physical examination is conducted, concentrating on areas relevant to the patient’s complaints.

Laboratory and Imaging Results: Any applicable laboratory test results, x-rays, or other diagnostic assessments conducted during the visit are documented.

Assessment/Problem List – Patient’s Problems

Assessment: A concise summary of the patient’s overall condition and the primary concern is given.

Problem List: A numerically enumerated list of identified issues is presented. Each problem is supported by findings from the subjective and objective sections.

ICD-10 Codes: Relevant ICD-10 codes for diagnosis are provided, ensuring accurate coding.

Plan – Treatment Plan

Diagnostic Plan: A thorough diagnostic approach is outlined, encompassing tests, procedures, consultations, and laboratory studies as necessary.

Treatment Plan: Patient education, pharmacotherapy if required, and other therapeutic interventions are elucidated. The plan addresses follow-up measures, including the scheduling of the next visit.

Case Study Paper Sections

Introduction: The patient’s identity, age, gender, and the medical issue at hand are introduced. The primary argument for nursing focus is presented.

Pathophysiology: The disease’s symptomatology, causative factors, and underlying mechanisms are explained, supported by scholarly sources.

History: The patient’s health history, including past diagnoses and treatments, is detailed, integrating information from authoritative sources.

Nursing Physical Assessment: All pertinent health parameters, such as blood pressure, ambulation status, and other critical aspects, are reported with specific values.

Related Treatments: Treatments administered due to the patient’s condition are elucidated, indicating the response to the disease.

Nursing Diagnosis & Patient Goal: The main nursing diagnosis is defined, addressing the primary problem. Nursing goals for the patient’s recovery are explained.

Nursing Interventions: Nursing strategies to achieve the goals are discussed, substantiated with references from nursing literature.

Evaluation: The effectiveness of nursing interventions is assessed, providing insights into the patient’s response.

Recommendations: Comprehensive patient recommendations are provided, with clinical findings compared and rationalized, backed by evidence.

References: A minimum of three scholarly resources, including at least one non-internet source, is cited accurately in APA format throughout the paper.

Mechanics: The writing is well-structured, organized, and devoid of spelling and grammatical errors.

Please use this template and the provided guidelines to create a comprehensive SOAP note and case study paper. Adhering to these principles will ensure the completion of a thorough and well-organized academic assignment.