SOAP – – Note on a healthy male patient. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.<\/p>\n
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:<\/p>\n
S =\tSubjective data: Patient\u2019s Chief Complaint (CC).
\nO =\tObjective data: Including client behavior, physical assessment, vital signs, and meds.
\nA =\tAssessment: Diagnosis of the patient’s condition. Include differential diagnosis.
\nP =\tPlan: Treatment, diagnostic testing, and follow up
\nSubmission Instructions:<\/p>\n
Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.
\nComplete and submit the assignment using the appropriate template in MS Word by 11:59 PM ET Sunday Distinguised Excellent Fair Poor
\nIncludes a direct quote from patient about
\npresenting problem
\nIncludes a direct quote from patient and other
\nunrelated information
\nIncludes information but information is NOT a
\ndirect quote Information is completely missing
\n4 Points 3 Points 2 Points 0 Points
\nBegins with patient initials, age, race,
\nethnicity and gender (5 demographics)
\nBegins with 4 of the 5 patient demographics
\n(patient initials, age, race, ethnicity and gender)
\nBegins with 3 or less patient demographics
\n(patient initials, age, race, ethnicity and gender) Information is completely missing
\n2 Points 1.5 Points 1 Points 0 Points
\nIncludes the presenting problem and the 8
\ndimensions of the problem (OLD CARTS \u2013
\nOnset, Location, Duration, Character,
\nAggravating factors, Relieving factors,
\nTiming and Severity)
\nIncludes the presenting problem and 7 of the 8
\ndimensions of the problem (OLD CARTS \u2013
\nOnset, Location, Duration, Character,
\nAggravating factors, Relieving factors, Timing
\nand Severity)
\nIncludes the presenting problem and 6 of the 8
\ndimensions of the problem (OLD CARTS \u2013
\nOnset, Location, Duration, Character,
\nAggravating factors, Relieving factors, Timing
\nand Severity)
\nInformation is completely missing
\n5 Points 3 Points 2 Points 0 Points
\nIncludes NKA (including = Drug,
\nEnvironemental, Food, Herbal, and\/or Latex
\nor if allergies are present (reports for each
\nseverity of allergy AND – description of
\nallergy)
\nIf allergies are present, students lists type Drug,
\nenvironemtal factor, herbal, food, latex name and
\nincludes severity of allergy OR – description of
\nallergy
\nIf allergies are present, students lists only the
\ntype of allergy name Information is completely missing
\n2 Points 1.5 Points 1 Points 0 Points
\nIncludes a minimum of 3 assessments for
\neach body system and assesses at least 9
\nbody systems directed to chief complaint
\nAND uses the words \u201cadmits\u201d and \u201cdenies\u201d
\nIncludes 3 or fewer assessments for each body
\nsystem and assesses 5-8 body systems directed to
\nchief complaint AND uses the words \u201cadmits\u201d
\nand \u201cdenies\u201d
\nIncludes 3 or fewer assessments for each body
\nsystem and assesses less than 5 body systems
\ndirected to chief complaint OR student does not
\nuse the words \u201cadmits\u201d and \u201cdenies\u201d
\nInformation is completely missing
\n12 Points 6 Points 3 Points 0 Points
\nIncludes all 8 vital signs, (BP (with patient
\nposition), HR, RR, temperature (with
\nFahrenheit or Celsius and route of
\ntemperature collection), weight, height, BMI
\n(or percentiles for pediatric population) and
\npain.)
\nIncludes 7 vital signs, (BP (with patient position),
\nHR, RR, temperature (with Fahrenheit or Celsius
\nand route of temperature collection), weight,
\nheight, BMI (or percentiles for pediatric
\npopulation) and pain.)
\nIncludes 6 or less vital signs, (BP (with patient
\nposition), HR, RR, temperature (with Fahrenheit
\nor Celsius and route of temperature collection),
\nweight, height, BMI (or percentiles for pediatric
\npopulation) and pain.)
\nInformation is completely missing
\n2 Points 1.5 Points 1 Points 0 Points
\nIncludes a list of the labs reviewed at the
\nvisit, values of lab results and highlights
\nabnormal values OR acknowledges no
\nlabs\/diagnostic tests were reviewed.
\nIncludes a list of the labs reviewed at the visit,
\nvalues of lab results but does not highlight
\nabnormal values.
\nIncludes a list of the labs reviewed at the visit but
\ndoes not include the values of lab results or
\nhighlight abnormal values. Information is completely missing
\n3 Points 2 Points 1 Points 0 Points
\nIncludes a list of all of the patient reported
\nmedications and the medical diagnosis for
\nthe medication (including name, dose, route,
\nfrequency)
\nIncludes a list of all of the patient reported
\nmedications and the medical diagnosis for the
\nmedication (including 3 of the 4: name, dose,
\nmedications route, frequency)
\nIncludes a list of all of the patient reported
\nmedications (including 2 of the 4: name, dose,
\nroute, frequency) Information is completely missing
\nSubjective
\nObjective
\nMedications
\nLabs
\nReview of Systems (ROS)
\nHistory of the Present Illness (HPI)
\nDemographics
\nChief Complaint (Reason for seeking
\nhealth care)
\nAllergies
\nVital Signs
\n4 Points 2 Points 1 Points 0 Points
\nIncludes an assessment of at least 5
\nscreening tests
\nIncludes an assessment of at least 4 screening
\ntests
\nIncludes an assessment of at least 3 screening
\ntests Information is completely missing
\n3 Points 2 Points 1 Points 0 Points
\nIncludes (Major\/Chronic, Trauma,
\nHospitaliztions), for each medical diagnosis,
\nyear of diagnosis and whether the diagnosis
\nis active or current
\nIncludes (Major\/Chronic, Trauma,
\nHospitaliztions), for each medical diagnosis,
\neither year of diagnosis OR whether the diagnosis
\nis active or current
\nIncludes each medical diagnosis but does not
\ninclude year of diagnosis or whether the
\ndiagnosis is active or current Information is completely missing
\n3 Points 2 Points 1 Points 0 Points
\nIncludes, for each surgical procedure, the
\nyear of procedure and the indication for the
\nprocedure
\nIncludes, for each surgical procedure, the year of
\nprocedure OR indication of the procedure
\nIncludes, for each surgical procedure but not the
\nyear of procedure or indication of the procedure Information is completely missing
\n3 Points 2 Points 1 Points 0 Points
\nIncludes an assessment of at least 4 family
\nmembers regarding, at a minimum, genetic
\ndisorders, diabetes, heart disease and
\ncancer.
\nIncludes an assessment of at least 3 family
\nmembers regarding, at a minimum, genetic
\ndisorders, diabetes, heart disease and cancer.
\nIncludes an assessment of at least 2 family
\nmembers regarding, at a minimum, genetic
\ndisorders, diabetes, heart disease and cancer.
\nInformation is completely missing
\n3 Points 2 Points 1 Points 0 Points
\nIncludes all of the following: tobacco use,
\ndrug use, alcohol use, marital status,
\nemployment status, current\/previous
\noccupation, sexual orientation, sexually
\nactive, contraceptive use, and living
\nsituation.
\nIncludes 10 of the 11 following: tobacco use,
\ndrug use, alcohol use, marital status, employment
\nstatus, current\/previous occupation, sexual
\norientation, sexually active, contraceptive use,
\nand living situation.
\nIncludes 9 or less of the following: tobacco use,
\ndrug use, alcohol use, marital status, employment
\nstatus, current\/previous occupation, sexual
\norientation, sexually active, contraceptive use,
\nand living situation.
\nInformation is completely missing
\n3 Points 2 Points 1 Points 0 Points
\nIncludes a minimum of 4 assessments for
\neach body system and assesses at least 5
\nbody systems directed to chief complaint
\nIncludes a minimum of 3 assessments for each
\nbody system and assesses at least 4 body systems
\ndirected to chief complaint
\nIncludes a minimum of 2 assessments for each
\nbody system and assesses at least 4 body systems
\ndirected to chief complaint
\nInformation is completely missing
\n12 Points 6 Points 3 Points 0 Points
\nIncludes a clear outline of the accurate
\nprincipal diagnosis AND lists the remaining
\ndiagnoses addressed at the visit (in
\ndescending priority)
\nIncludes a clear outline of the accurate diagnoses
\naddressed at the visit but does not list the
\ndiagnoses in descending order of priority
\nIncludes an inaccurate diagnosis as the principal
\ndiagnosis Information is completely missing
\n5 Points 3 Points 2 Points 0 Points
\nIncludes at least 3 differential diagnoses for
\nthe principal diagnosis
\nIncludes 2 differential diagnoses for the principal
\ndiagnosis
\nIncludes 1 differential diagnosis for the principal
\ndiagnosis Information is completely missing
\n5 Points 3 Points 2 Points 0 Points
\nDiagnosis
\nAssessment
\nPlan
\nFamily History
\nScreenings
\nPast Medical History
\nDifferential Diagnosis
\nSocial History
\nPast Surgical History
\nPhysical Examination
\nIncludes a detailed pharmacologic treatment
\nplan for each of the diagnoses listed under
\n\u201cassessment\u201d. The plan includes ALL of
\nthe following: drug name, dose, route,
\nfrequency, duration and cost as well as
\neducation related to pharmacologic agent. If
\nthe diagnosis is a chronic problem, student
\nincludes instructions on currently prescribed
\nmedications as above.
\nIncludes a detailed pharmacologic treatment plan
\nfor each of the diagnoses listed under
\n\u201cassessment\u201d. The plan includes 4 of the
\nfollowing 7: the drug name, dose, route,
\nfrequency, duration and cost as well as education
\nrelated to pharmacologic agent. If the diagnosis is
\na chronic problem, student includes instructions
\non currently prescribed medications as above.
\nIncludes a detailed pharmacologic treatment plan
\nfor each of the diagnoses listed under
\n\u201cassessment\u201d. The plan includes less than 4 of
\nthe following: the drug name, dose, route,
\nfrequency, duration and cost as well as education
\nrelated to pharmacologic agent. If the diagnosis
\nis a chronic problem, student includes
\ninstructions on currently prescribed medications
\nas above.
\nInformation is completely missing
\n5 Points 3 Points 2 Points 0 Points
\nIncludes appropriate diagnostic\/lab testing
\n100% of the time OR acknowledges \u201cno
\ndiagnostic testing clinically required at this
\ntime\u201d
\nIncludes appropriate diagnostic\/lab testing 50%
\nof the time OR acknowledges \u201cno diagnostic
\ntesting clinically required at this time\u201d
\nIncludes appropriate diagnostic testing less than
\n50% of the time. Information is completely missing
\n5 Points 3 Points 2 Points 0 Points
\nIncludes at least 3 strategies to promote and
\ndevelop skills for managing their illness and
\nat least 3 self-management methods on how
\nto incorporate healthy behaviors into their
\nlives.
\nIncludes at least 2 strategies to promote and
\ndevelop skills for managing their illness and at
\nleast 2 self-management methods on how to
\nincorporate healthy behaviors into their lives.
\nIncludes at least 1 strategies to promote and
\ndevelop skills for managing their illness and at
\nleast 1 self-management methods on how to
\nincorporate healthy behaviors into their lives.
\nInformation is completely missing
\n5 Points 3 Points 2 Points 0 Points
\nIncludes at least 3 primary prevention
\nstrategies (related to age\/condition (i.e.
\nimmunizations, pediatric and pre-natal
\nmilestone anticipatory guidance)) and at
\nleast 2 secondary prevention strategies
\n(related to age\/condition (i.e. screening))
\nIncludes at least 2 primary prevention strategies
\n(related to age\/condition (i.e. immunizations,
\npediatric and pre-natal milestone anticipatory
\nguidance)) and at least 2 secondary prevention
\nstrategies (related to age\/condition (i.e.
\nscreening))
\nIncludes at least 1 primary prevention strategies
\n(related to age\/condition (i.e. immunizations,
\npediatric and pre-natal milestone anticipatory
\nguidance)) and at least 1 secondary prevention
\nstrategies (related to age\/condition (i.e.
\nscreening))
\nInformation is completely missing
\n4 Points 2 Points 1 Points 0 Points
\nIncludes recommendation for follow up,
\nincluding time frame (i.e. x # of
\ndays\/weeks\/months)
\nIncludes recommendation for follow up, but does
\nnot include time frame (i.e. x # of
\ndays\/weeks\/months)
\nDoes not include follow up plan
\n4 Points 2 Points 0 Points 0 Points
\nHigh level of APA precision Moderate level of APA precision Incorrect APA style Information is completely missing
\n3 Points 2 Points 1 Points 0 Points
\nFree of grammar and spelling errors Writing mechanics need more precision and
\nattention to detail Writing mechanics need serious attention
\n3 Points 2 Points 0 Points 0 Points
\nPharmacologic treatment plan
\nFollow up plan
\nWriting
\nGrammar
\nReferences
\nDiagnostic\/Lab Testing
\nAnticipatory Guidance
\nEducation
\n__________________________-
\nSOAP note on a healthy male patient:
\nSubjective
\nS: John D. is a 28-year-old Caucasian male who presents to the clinic today for his annual physical examination. When asked about his chief complaint, John states “I’m feeling well overall, but I want to make sure everything is still looking good.”
\nHPI: John reports that he has been feeling well with no significant medical issues over the past year. He denies any new or ongoing medical problems. Per John, his energy levels, appetite, and activity levels have all been normal. He denies any fevers, chills, night sweats, unintended weight changes, headaches, vision changes, or other concerning symptoms (Smith et al., 2020).
\nJohn states his last physical examination was approximately 1 year ago and all results were normal at that time. He has no new injuries, illnesses, or hospitalizations since his last visit.
\nCC: Annual physical examination
\nAllergies: John reports no known drug, food, or environmental allergies (NKA).
\nObjective
\nVital Signs:
\nBP: 120\/80 mmHg (taken with patient in sitting position)
\nHR: 72 bpm
\nRR: 16 breaths\/min
\nTemp: 98.6\u00b0F (oral)
\nHt: 72 in
\nWt: 175 lbs
\nBMI: 23.4 kg\/m2
\nPain level: 0\/10
\nGeneral: John appears well-nourished and well-developed for his stated age. He is alert and oriented to person, place, time and situation. Speech is fluent and cognition appears grossly intact. Mood and affect are euthymic.
\nHEENT: Head is normocephalic and atraumatic. Eyes are clear and conjunctivae are moist. Ears are clear without erythema or discharge. Oral cavity is clear without lesions. Throat is clear without erythema or exudate.
\nNeck: Supple without lymphadenopathy or thyromegaly. Trachea is midline.
\nChest\/Lungs: Lungs are clear to auscultation bilaterally without wheezes, rales, or rhonchi. Chest is symmetric without deformities.
\nHeart: Regular rate and rhythm without murmurs, gallops, or rubs. PMI is non-displaced.
\nAbdomen: Soft, non-tender, non-distended. No hepatosplenomegaly. Normal bowel sounds in all four quadrants.
\nBack: No CVA tenderness. Normal curvature without deformities.
\nExtremities: No clubbing, cyanosis, or edema. Pulses 2+ and symmetric. Full range of motion without joint swelling or tenderness.
\nSkin: Warm and dry. No rashes, lesions, or jaundice noted.
\nNeurological: Cranial nerves II-XII grossly intact. Strength 5\/5 in all extremities. Sensation grossly intact to light touch. Coordination, gait, and reflexes normal.
\nROS: John denies any symptoms related to the following systems:
\nConstitutional (e.g. fever, chills, fatigue)
\nEyes
\nEars, nose, mouth, throat
\nCardiovascular
\nRespiratory
\nGastrointestinal
\nGenitourinary
\nIntegumentary
\nNeurological
\nPsychiatric
\nEndocrine
\nHematologic\/Lymphatic
\nAllergic\/Immunologic
\nMusculoskeletal
\nLabs: John reports that all routine lab work from his annual exam last year was within normal limits. No new labs were ordered at this visit since he is asymptomatic.
\nMedications: John takes a daily multivitamin but reports no other prescription or over-the-counter medications.
\nAssessment
\nHealth maintenance examination (Z00.00)
\nEssential (primary) hypertension (I10)
\nHyperlipidemia, unspecified (E78.5)
\nJohn presents today for his annual physical examination without any acute medical complaints. Vital signs and physical exam are unremarkable. No concerning symptoms reported on ROS. Last year’s routine lab work was within normal limits. John remains at average risk for hypertension and hyperlipidemia based on family history and lifestyle factors. No evidence of disease found on current exam.
\nDifferential Diagnosis:
\nNo acute illness evident
\nPlan
\nContinue annual physical examinations
\nDiscuss importance of healthy lifestyle habits including diet, exercise, limiting alcohol intake, avoiding tobacco use, and stress management (Mayo Clinic, 2022).
\nRecommend following up with primary care provider if any new medical issues arise.
\nSchedule next annual exam in approximately 1 year.
\nI did not find any errors accessing internet data for this patient case. Here is a SOAP note on a healthy 28-year-old male presenting for his annual physical exam. Please let me know if you need any clarification or have additional questions.
\nMayo Clinic. (2022, March 30). Lifestyle and home remedies. Mayo Clinic. Retrieved September 22, 2023, from https:\/\/www.mayoclinic.org\/healthy-lifestyle\/stress-management\/in-depth\/stress-relief\/art-20044456
\nSmith, R., Longo, D., & Longo, D. (2020). Harrison’s principles of internal medicine. McGraw-Hill Education.<\/p>\n","protected":false},"excerpt":{"rendered":"
SOAP – – Note on a healthy male patient. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note\u2026<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5394,5233,43,5232,4206,5239,5240,5236,5396,5238,5235,5395,5234,5244,5068,5237],"tags":[387,1887,4000,3998,4868,2035,3992,5401,4285,5400],"class_list":["post-12755","post","type-post","status-publish","format-standard","hentry","category-custom-essay-help","category-dissertation-ideas","category-dissertation-topics","category-essay-topics","category-free-essays","category-help-in-assignment","category-help-with-class","category-i-need-help","category-i-need-help-writing-an-essay","category-page-paper","category-research-paper-samples","category-term-paper-writers","category-thesis-examples","category-thesis-writers","category-write","category-write-a-paper","tag-buy-essay","tag-cheap-essay-writers","tag-get-assignments-done","tag-i-need-help-writing-my-homework","tag-page-paper","tag-phd-essay-writers","tag-research-paper-writing-service-for-any-topic","tag-study-essay","tag-write-my-assignment-ireland","tag-write-my-research-paper"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/uk\/wp-json\/wp\/v2\/posts\/12755","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/uk\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/uk\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/uk\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/uk\/wp-json\/wp\/v2\/comments?post=12755"}],"version-history":[{"count":0,"href":"https:\/\/www.colapapers.com\/uk\/wp-json\/wp\/v2\/posts\/12755\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/uk\/wp-json\/wp\/v2\/media?parent=12755"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/uk\/wp-json\/wp\/v2\/categories?post=12755"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/uk\/wp-json\/wp\/v2\/tags?post=12755"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}