Nurs 6565 PRAC Comprehensive SOAP Note
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Comprehensive SOAP Note Template
Patient Initials: _GD______ Age: _____49__ Gender___M____
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Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
O = Onset of symptom (acute/gradual)
L= Location
D= Duration (recent/chronic)
C= Character
A= Associated symptoms/aggravating factors
R= Relieving factors
T= Treatments previously tried—response? Why discontinued?
S= Severity
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC):
“I’m here for my diabetes”
History of Present Illness (HPI):
This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e., 34-year-old AA male). You must include the seven attributes of each principal symptom:
- Location
- Quality
- Quantity or severity
- Timing, including onset, duration, and frequency
- Setting in which it occurs
- Factors that have aggravated or relieved the symptom
- Associated manifestations
Medications:
Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies:
Include specific reactions to medications, foods, insects, and environmental factors.
Past Medical History (PMH):
Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.
Past Surgical History (PSH):
Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable,
include obstetric history, menstrual history, methods of contraception, and sexual function.
Personal/Social History:
Include tobacco use, alcohol use, drug use, patient’s interests, ADLs and IADLs if applicable, and exercise and eating habits.
Immunization History:
Include last Tdap, flu, pneumonia, etc.
Significant Family History:
Include history of parents, grandparents, siblings, and children.
Lifestyle:
Include cultural factors, economic factors, safety, and support systems.
Review of Systems: From head to toe, include each system that covers the chief complaint, history of present illness, and history (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.
Hematologic:
Endocrine:
Allergic/Immunologic:
OBJECTIVE DATA: From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history if you are doing a total H&P. Do not use WNL or normal. You must describe what you see.
Physical Exam:
Vital signs:
Include vital signs, height, weight, and BMI.
General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, affect, and reactions to people and things.
HEENT:
Neck:
Chest/Lungs: Always include this in your PE.
Heart/Peripheral Vascular: Always include the heart in your PE.
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.
PLAN:
Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, X-rays, or other diagnostics. Support the treatment plan with evidence and guidelines.
Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.
Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies, such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.
REFLECTION: Reflect on your clinical experience and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence?
Please use the template uploaded. please follow the directions carefully. below is the Pt's story.
49 year old here for Ed f/u
Was seen in ED on 6/20 for intractable headache and was found to be hyperglycemic with an A1C of 18.1
#Diabetes
New diabetes diagnosis. A1C 18.1 in ED- today 14.1
On metformin 500 mg bid. Started in ED.Taking as prescribed without SEs.
Says his meals usually consist of
Breakfast :orange juice with sugar with fried turnover.
Lunch:Rice beans and meat
Dinner:Rice beans and meat
had increased thirst and urination. states this has resolved since he started taking metformin.
Denies SOB, chest pain, dizziness, palpitations, weakness, nausea, vomiting.
VS
BP 121/68 Pulse 75 Temp 98.1 °F Wt 175 lb 9.6 oz| SpO2 97% BMI 26.61
Medications: Lipitor 20 mg daily, metformin 1000 mg BID.
immunizations: Tdap:7/7/2022, PCV20 7/7/2022.
Alcohol
Drinks 56 beers per week.
3-5 shots of whisky weekly
6 nips of powerball weekly-stopped 3 weeks ago.
Does not think he has drinking problem, states he can go days without drinking. Denies ever having withdrawal sxs.
Family hx: Mother deceased-diabetes, HTN. Father: alcohol abuse, 1 brother 1 sister : good health. Maternal grandmother: diabetes. Paternal grandfather: prostate cancer.
former smoker:quit 2012.
Comprehensive Notes:
HPI – complete OLD CART information
PMH
PSH
OB/GYN
Mental Health
SH > Tobacco use, Alcohol Use, Drugs, Sexual History
Preventative History
Allergies
Medications
ROS – 6 systems
PE – 8 systems
DD – three for each diagnosis
Plan – Diagnostics
Medications
Referrals
Follow-up
Rubric Detail
A rubric lists grading criteria that instructors use to evaluate student work. Your instructor linked a rubric to this item and made it available to you. Select Grid View or List View to change the rubric's layout.
Content
Name: PRAC_6565_Week8_Assignment1_Rubric
Grid View
List View
Excellent Good Fair Poor
Create documentation in the Comprehensive SOAP Note Template about the patient you selected.
In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Current medications
• Allergies
• Patient medical history (PMHx), including immunization status, social and substance history, family history, past surgical procedures, mental health, safety concerns, reproductive history
• Review of systems
Points Range:9 (9.00%) - 10 (10.00%)
The response throughly and accurately describes the patient's subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis.
Points Range:8 (8.00%) - 8 (8.00%)
The response accurately describes the patient's subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis.
Points Range:7 (7.00%) - 7 (7.00%)
The response describes the patient's subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies.
Points Range:0 (0.00%) - 6 (6.00%)
The response provides an incomplete or inaccurate description of the patient's subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing.
In the Objective section, provide:
• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
Points Range:9 (9.00%) - 10 (10.00%)
The response thoroughly and accurately documents the patient's physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
Points Range:8 (8.00%) - 8 (8.00%)
The response accurately documents the patient's physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.
Points Range:7 (7.00%) - 7 (7.00%)
Documentation of the patient's physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.
Points Range:0 (0.00%) - 6 (6.00%)
The response provides incomplete or inaccurate documentation of the patient's physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
In the Assessment section, provide:
• At least 3 differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.
Points Range:23 (23.00%) - 25 (25.00%)
The response lists at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected.
Points Range:20 (20.00%) - 22 (22.00%)
The response lists at least three different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the conditions selected.
Points Range:18 (18.00%) - 19 (19.00%)
The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.
Points Range:0 (0.00%) - 17 (17.00%)
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
In the Plan section, provide:
• A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits.
• Reflections on the case describing insights or lessons learned.
• A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors.
Points Range:27 (27.00%) - 30 (30.00%)
The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. Reflections on the case demonstrate strong critical thinking and synthesis of ideas. A thorough and accurate disucssion of health promotion and disease prevention related to the case is provided.
Points Range:24 (24.00%) - 26 (26.00%)
The response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. Reflections on the case demonstrate critical thinking. An accurate disucssion of health promotion and disease prevention related to the case is provided.
Points Range:21 (21.00%) - 23 (23.00%)
The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. Reflections on the case demonstrate adequate understanding of course topics. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies.
Points Range:0 (0.00%) - 20 (20.00%)
The response does not address all diagnoses or is missing elements of the treatment plan. Reflections on the case are vague or missing. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing.
Provide at least three evidence-based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than five years old) and support the treatment plan in following current standards of care.
Points Range:9 (9.00%) - 10 (10.00%)
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions.
Points Range:8 (8.00%) - 8 (8.00%)
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions.
Points Range:7 (7.00%) - 7 (7.00%)
Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan.
Points Range:0 (0.00%) - 6 (6.00%)
Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence-based, or do not support the treatment plan.
Written Expression and Formatting - Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused--neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
Points Range:5 (5.00%) - 5 (5.00%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.
A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
Points Range:4 (4.00%) - 4 (4.00%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.
Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
Points Range:3.5 (3.50%) - 3.5 (3.50%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time.
Purpose, introduction, and conclusion of the assignment is vague or off topic.
Points Range:0 (0.00%) - 3 (3.00%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time.
No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting - English writing standards:
Correct grammar, mechanics, and proper punctuation
Points Range:5 (5.00%) - 5 (5.00%)
Uses correct grammar, spelling, and punctuation with no errors.
Points Range:4 (4.00%) - 4 (4.00%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
Points Range:3.5 (3.50%) - 3.5 (3.50%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.
Points Range:0 (0.00%) - 3 (3.00%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting - The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
Points Range:5 (5.00%) - 5 (5.00%)
Uses correct APA format with no errors.
Points Range:4 (4.00%) - 4 (4.00%)
Contains a few (1 or 2) APA format errors.
Points Range:3.5 (3.50%) - 3.5 (3.50%)
Contains several (3 or 4) APA format errors.
Points Range:0 (0.00%) - 3 (3.00%)
Contains many (≥ 5) APA format errors.
Name:PRAC_6565_Week8_Assignment1_Rubric
Comprehensive SOAP Note Template sample approach
Patient Initials: _GD______ Age: _____49__ Gender___M____
SUBJECTIVE DATA:
Chief Complaint (CC):
“I’m here for my diabetes”
History of Present Illness (HPI): GD is a 49-year old male who presents to the ED seeking to follow up on his diabetes. A while ago, he was evaluated for an untreatable headache, and it was discovered that he had hyperglycemia, with an A1C level of 18. He states that he had an upsurge in both his thirst and his need to urinate, but that both of these symptoms have subsided after he began taking metformin. He denies the presence of symptoms such as vomiting, nausea, weakness, palpitations, dizziness, chest pain, or shortness of breath.
Medications:
Lipitor 20 mg daily, metformin 1000 mg BID
Allergies:
Denies medication, food, seasonal, or environmental allergies.
Past Medical History (PMH):
History of diabetes. Denies history of hospitalizations or risky sexual behaviors.
Past Surgical History (PSH):
No surgical history.
Personal/Social History: Reports drinking 56 beers and 3-5 shots of whisky per week. Reports drinking 6 nips of powerball weekly, but stopped 3 weeks ago.
Reports he can go days without drinking. Denies ever having withdrawal symptoms. States that his meals usually consist of:
- Breakfast: orange juice with sugar with fried turnover.
- Lunch: Rice beans and meat
- Dinner: Rice beans and meat
Immunization History:
Tdap 7/7/2022, PCV20 7/7/2022.
Significant Family History:
Mother- deceased, history of diabetes, hypertension.
Father- alcohol abuse
Brother- good health
Sister- good health
Maternal grandmother: diabetes.
Paternal grandfather: prostate cancer, former smoker: quit 2012.
Lifestyle:
Denies any safety issues. Does not mention any cultural or economic factors.
Review of Systems:
General: Denies recent weight changes, weakness, fatigue, or fever.
HEENT: Denies history of head trauma or injury. Denies eye pain or visual problems. Denies ear pain, discharge, or hearing problems. Denies nasal issues or loss of sense of smell. Denies sore throat or difficulty swallowing.
Neck: Denies swollen lymph nodes
Breasts: Denies breast pain, soreness, lumps, or discharge.
Respiratory: denies shortness of breath, cough, or wheezing.
Cardiovascular/Peripheral Vascular: Denies chest pain, pressure or tightness. Denies edema or palpitations.
Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea or constipation.
Genitourinary: Denies increased frequency in urination or pain on urination.
Musculoskeletal: Denies muscle pain or injury. Denies joint pain, stiffness, or back pain.
Psychiatric: Denies history of depression or anxiety.
Neurological: Denies headache, dizziness, vertigo, syncope, or sense of disequilibrium.
Skin: Denies rashes, lumps, sores, itching, or lesions.
Hematologic: Denies bleeding or history of anemia.
Endocrine: Denies cold or heat intolerance, night sweats, or poydipsia.
Allergic/Immunologic: Denies rash or hives
OBJECTIVE DATA:
Physical Exam:
Vital signs: BP 121/68 Pulse 75 Temp 98.1 °F Wt 175 lb SpO2 97% BMI 26.61
General: Pleasant male, in no acute distress. Well-dressed, well-groomed, and well-nourished, with steady gait. Clear and coherent speech with appropriate facial expressions. Cooperative and aware of what is happening in his surroundings.
HEENT: Head: normocephalic and atraumatic, no abnormalities. Eyes: moist and pink conjunctiva, white sclera. Ears: No drainage from ear canals. Nose: moist and pink mucus membranes. No discharge from ear canals. Throat: Moist and pink oral mucosa, no swelling.
Neck: no deformities, signs of trauma, or external skin changes.
Chest/Lungs: Symmetric chest. Unlabored breathing. Lungs clear to auscultation bilaterally.
Heart/Peripheral Vascular: S1, S2 noted no murmurs, gallops, or rubs. No edema in the extremities. Strong and regular pulses bilaterally. Capillary refill less than 3 seconds.
Abdomen: symmetric, soft, round abdomen, no tenderness or abnormalities. Tympany noted in all areas. Normoactive bowel sounds in all quadrants.
Genital/Rectal: No hemorrhoids or bleeding from the rectum noted
Musculoskeletal: legs and arms are symmetrical, no swelling. No tenderness, joint stiffness, or swelling. Full range of motion in lower and upper extremities.
Neurological: Alert and oriented X 4, with normal speech. Intact sensation bilaterally. No motor déficits, 5/5 muscle strength bilaterally.
Skin: No tenting, cyanosis, or rash noted.
ASSESSMENT:
Differential Diagnosis
Diabetes (Primary diagnosis): Diabetes is a chronic condition that manifests itself either when the pancreas fails to secrete an adequate amount of insulin or when the body is unable to make proper use of the insulin it does generate. A major side effect of untreated diabetes is hyperglycemia, often known as high blood sugar. Over time, hyperglycemia causes catastrophic destruction to several of the body’s functions, most notably the neurons and blood vessels. The diagnosis and management of diabetes include doing a blood test to determine the patient’s sugar level. The fasting glucose test, A1c test, and the random glucose test are the three different tests that may assess the amount of sugar in the blood. A solid sign of diabetes is a HbA1c level of 6.5 percent or above (Matoori et al., 2020).
Obesity: Obesity is a complicated condition that is caused by having an excessive quantity of fat in the body. The issue of obesity is more than simply one of appearance. Obesity is often caused by a combination of genetic, physiological, and environmental variables, as well as decisions about nutrition, level of physical activity, and exercise (Fruh, 2017). The body mass index (BMI) is a common tool for diagnosing obesity; a BMI of 25 or more indicates that a person is obese. Glycation of hemoglobin may be increased regardless of glucose levels if obesity is present due to the systemic oxidative stress that comes along with it. Therefore, A1c values in obese individuals may be disproportionately high for a particular glycemic concentration.
Hyperglycemia: When there is an abnormally high level of sugar in the blood, a condition known as hyperglycemia may develop. This occurs either because the body does not have enough insulin or because the body is unable to make good use of the insulin that it does have. Diabetes mellitus is the co-morbidity that is seen most often with this condition. Blood tests such as the fructosamine test, A1C test, or fasting plasma glucose (FPG) may be used to diagnose hyperglycemia (Mouri & Badireddy, 2021).
Prehypertension: When a person’s blood pressure is higher than normal but not quite high enough to be diagnosed as high blood pressure, the individual is said to have prehypertension. It may be the first step in developing hypertension. It indicates that the person has a greater risk of developing hypertension. Because of this, they have a higher risk of illnesses that might potentially take their lives, including a heart attack or a stroke (Han et al., 2018). A systolic pressure from 120–139 mmHg or a diastolic pressure from 80–89 mmHg indicates prehypertension.
PLAN:
Treatment Plan: A combination of pharmacological and nonpharmacological approaches is required for the treatment of diabetes. In terms of the patient’s pharmacological treatment, the patient should continue taking metformin at a dosage of 1000 milligrams twice daily. Metformin is an oral medication that, when taken as directed, may enhance the way in which the body makes use of insulin, which, in turn, can bring about a reduction in overall blood sugar levels (Lv & Guo, 2020). Diets low in calories, along with frequent rigorous exercise and weight reduction constitute nonpharmacological strategies.
Health Promotion: The patient should be taught on the need of fostering healthy living by promoting healthy eating, physical exercise, and mental well-being. Emotional distress may be brought on by diabetes, in addition to the physical symptoms and difficulties it brings. A person who has diabetes is required to make several modifications to their lifestyle, some of which include modifying their exercise and diet patterns, consistently using medications, performing self-monitoring, establishing coping mechanisms, rearranging meal times, and modifying family routines and social activities (Tynan, 2020).
Disease Prevention: The development of diabetes may be prevented or delayed by making very little adjustments to one’s lifestyle, which have been demonstrated to be beneficial. People should do the following things to help avoid diabetes and the issues that come with it: eating a healthy diet, being physically active, maintaining a healthy body weight, and avoiding tobacco use. Additionally, the American Diabetes Association (2021) suggests that all persons who are 45 years of age or older undergo regular screening with diagnostic testing to check for diabetes.
.
REFLECTION: What I learned from this experience is that treatment of diabetes should focus on achieving blood glucose levels that are as near to normal as may be achieved without jeopardizing patient safety. Treatment for diabetes must also include steps to bring under control the patient’s blood pressure and cholesterol levels because diabetes is associated with a significantly increased risk of cardiovascular disease and peripheral artery disease. There is nothing I would do differently since every intervention recommended is evidence-based. I agree with my preceptor on the diagnosis and the choice of the treatment regimen.
References
American Diabetes Association. (2021). 2. Classification and diagnosis of diabetes: standards of medical care in diabetes—2021. Diabetes care, 44(Supplement 1), S15-S33. https://doi.org/10.2337/dc21-s002
Fruh, S. M. (2017). Obesity. Journal of the American Association of Nurse Practitioners, 29(S1), S3-S14. https://doi.org/10.1002/2327-6924.12510
Han, M., Li, Q., Liu, L., Zhang, D., Ren, Y., Zhao, Y., Liu, D., Liu, F., Chen, X., Cheng, C., Guo, C., Zhou, Q., Tian, G., Qie, R., Huang, S., Wu, X., Liu, Y., Li, H., Sun, X., … Hu, D. (2019). Prehypertension and risk of cardiovascular diseases. Journal of Hypertension, 37(12), 2325-2332. https://doi.org/10.1097/hjh.0000000000002191
Lv, Z., & Guo, Y. (2020). Metformin and its benefits for various diseases. Frontiers in Endocrinology, 11. https://doi.org/10.3389/fendo.2020.00191
Matoori, S. (2022). Diabetes and its Complications. ACS Pharmacology & Translational Science.
Mouri, M., & Badireddy, M. (2021). Hyperglycemia. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430900/
Tynan, A. (2020). Supporting positive lifestyle changes among patients with diabetes mellitus type 2. https://doi.org/10.33015/dominican.edu/2020.nurs.st.14
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