Comprehensive Final SOAP Note

  

Comprehensive Final SOAP Note

Write a SOAP note for a patient seen in a practicum that required a comprehensive history and physical examination. Submit your note, following the SOAP Rubric (This is very important). Support your paper with 3 nursing articles not older than 5 yrs. Please see the attached document for an example of a soap note. However, remember this is a more detailed comprehensive Soap Note So make sure to cover the Rubric Requirement.

SOAP Note Rubric

Total Points

[SOAP Note Rubric] – 100 Points Save Time On Research and Writing Hire a Pro to Write You a 100% Plagiarism-Free Paper. Get My Paper
Criteria	Exemplary Exceeds Expectations	Advanced Meets Expectations	Intermediate Needs Improvement	Novice Inadequate		Total Points
Subjective – 25% Information about the patient (3 points) · Name (initials only); age, and gender · Source of information; note relationship to patient, if relevant · Reliability of information Chief Complaint (1 point) History of Presenting Illness (8 points) · Location · Quality · Quantity or severity · Timing (onset, duration, frequency) · Setting in which it occurs · Factors that aggravate or relieve the symptoms · Associated manifestations Review of Focus System(s) (5 points) Medications/Allergies (3 points) History (5 points) · Past Medical History · Past Surgical History · Family History · Social History · Health Maintenance Practices	Patient described in appropriate detail Concise and clear chief complaint as described by patient HPI includes all components with appropriate detail Comprehensive review of focus system(s) includes pertinent negatives Name, dose, route, and frequency of prescribed and over-the-counter medications noted, including compliance; Allergies to medications and reaction noted Comprehensive health history is appropriate to reason for visit and includes pertinent negatives 25 points	Patient described in appropriate detail Concise and clear chief complaint as described by patient HPI missing minor detail Comprehensive review of focus system(s) Name, dose, route, and frequency of prescribed and over-the-counter medications noted, including compliance; Allergies to medications and reaction noted Comprehensive health history is appropriate to reason for visit 22 points	1 detail missed in patient description Chief complaint as described by patient, may not be concise or clear HPI missing 1 component or significant detail Review of focus system missing 1-2 components Medication history missing 1-2 components Health history not appropriate for reason for visit or missing 1-2 components 19 points	>2 details missed in patient description Chief complaint not identified, concise, or clear HPI missing >2 components and significant detail Review of focus system(s) missing >3 components Medication history missing >3 components Health history missing >3 components 17 points	25
Objective – 30% Physical exam includes appropriate areas for Chief Complaint, History of Presenting Illness, and Review of Systems (20 points) Appropriate techniques of examination used to identify pertinent findings (10 points)	Appropriate areas and systems included in physical assessment Comprehensive techniques of observation, palpation, percussion, and auscultation noted including special assessments as appropriate 30 points	Missing 1 expected area of assessment Appropriate techniques of examination used but special assessment technique missed 26 points	Missing 2 expected areas of assessment One basic technique of examination missed 23 points	Missing >3 expected areas of assessment >2 techniques of examination missed 20 points	30
Assessment – 20% Differential diagnoses are supported by subjective and objective findings (15 points) Scholarly resources support differential diagnoses (5 points)	Three differential diagnoses are supported by findings and include worst case scenario Rationale for differential diagnoses provided by scholarly resources 20 points	Three differential diagnoses include worst case scenario but one diagnosis may not be fully supported by findings Rationale for differential diagnoses provided by scholarly resources 17 points	Differential diagnoses may or may not include worst case scenario and 2 differential diagnoses not supported by findings Rationale for all differential diagnoses not provided by scholarly resources 15 points	<3 differential diagnoses identified, or differential diagnoses not supported by findings and do not include worst case scenario Scholarly resources not provided or do not support differential diagnoses 13 points	20
Plan – 15% Comprehensive plan to address likely differential diagnosis includes (9 points) · Diagnostic testing · Pharmacologic intervention · Non-pharmacologic intervention · Referrals · Patient education · Follow-up Plan is supported by appropriate and current practice guidelines (6 points)	Comprehensive plan includes all components Appropriate and current guidelines cited 15 points	Plan missing 1 of the identified components Appropriate and current guidelines cited 13 points	Plan missing 2 of the identified components Guidelines are not current or appropriate for identified problem 12 points	Plan missing >3 of the identified components Guidelines for plan not cited 10 points	15
Documentation – 10% Documentation follows SOAP template, is logical, and in correct format (10 points)	Logical and systematic organization of data Correct terminology, spelling, and grammar Scholarly resources noted in correct APA format 10 points	Logical and systematic organization of data Terminology, spelling, grammar or format errors (1-3) 8 points	Minor errors in organization of data Terminology, spelling, grammar, or format errors (4-5) 7 points	Disorganized flow of data Terminology, spelling, grammar or format errors (>5) 6 points	10
100

Neurological Examination physical Assessment

Soap Note

Israel Ulubiyo

Week 13 Assignment: Neurological Examination

Soap Notes:

Patient Names: Martha, J.

DOB: 5/6/1962

AGE: 58yrs old

Ethnicity: African /American

Source of Information: Assessment Done by Nurse Practitioner Debra

Chief Complaint: Normal follow-up visit with the Doctor. Post Parkinson Disease Diagnosis.

HISTORY OF PRESENT ILLNESS:

 Mrs. Martha, J returns to the clinic with her husband for a Post Parkinson’s disease diagnosis follow-up. she was last seen in the office few months ago. In general, she is doing about the same. she thinks that perhaps her balance might be occasionally off, though she has had no falls. She remains active, going for walks three times a week.

Subjective

After a thorough neurological assessment by the doctor, Patient is tolerating the medications very well without any sleep disturbance, excessive somnolence, nausea or vomiting. Patient stated she’s doing very well. She is very independent with everything like her daily living activities and self ambulates independently without any issues. Since her last visits to the doctors, she has had tremendous improvement with all her symptoms of parkinsonism. She has monetized her diet, limited salt and sodium intake. She has had zero episodes of syncope or presyncope episode since her last doctor visit. She stated that her tremor is currently intermittently and mild. It is mostly in the left hand. She continues to do hand and wrist exercise, yoga twice a week and walk out on the treadmill three times a week. she denies any hallucinations, depression, cognitive deficits, delusions, dysphagia, hypophonia, dysarthria, falls, freezing of gait, or sensory changes. She sometimes has mild constipation and bladder urgency. which improves with diet modification and proper fluid and fiber intake.

REVIEW OF SYSTEMS

· General: Patient denies any weight loss/ or excessive gain, no fever, fatigue, weakness or night sweats

· Skin: patient denies any skin issues, rashes, or itching. Patient reports the use of sunscreen whenever needed especially when outside in the sun

· Hair/nails: patient reports no change in her nails or hair loss.

· Head: patient denies any headaches, or any history of head injury, or dizziness

· Eyes: Patient denies any difficulty with vision, pain or dryness, stated he uses glasses.

· Ears: Patient denies any ear problems, no hearing aids with hearing, denies any pain, vertigo, tinnitus, discharge, or any history infections

· Nose and sinus: patient reports that she sometimes gets occasional colds or sinus infections.

· Mouth and throat: Patient deny any mouth problems or infection, denies any bleeding from the gums, no sore throat, she stated that her last dental exam was normal, denies any change in taste or swallowing.

· Neck: Patient denies any pain or stiffness.

· Breasts: Patient denies any breast pain or lumps during her routine self-assessment

· Respiratory system: Patient denies any respiratory issues, no wheezing, no Sob or any history lung disorder

· Cardiovascular: Patient denies any cardiac concern or pain, she reports no signs heart trouble or difficulty breathing.

· Peripheral Vascular: Patient denies any leg cramps, varicose veins, denies any history of blood clots, swelling, coldness or numbness

· Gastrointestinal: Patient reports good appetite, reports food intolerances, denies any concerns with heartburn, she stated she has normal bowel movements.

· Urinary: Patient denies any difficulty urinating, denies any burning sensation, nocturia, polyuria, hesitancy, straining

· Genitals: Patient denials any Genitalia Development or issues

· Sexual health: Patient reports Normal sexual habit.

· Musculoskeletal system: Patient denies any muscle or joint pains, stiffness, arthritis, gout, back pain, swelling, redness, stiffness, ROM

· Neuro: Patient Denies any fainting, blackouts, seizures, however reports signs of weakness, paralysis, numbness, tingling, tremors in her lower extremities. Especially on the right side of her body

· Psyche: Patient denies any sign of depression, nervousness, anxiety or abnormal mood changes.

· Hematologic: Patient denies any sign of bleeding, tiredness or bruising.

· Endocrine: Patient denies any history of diabetes diagnosis or issues.

FUNCTIONAL ASSESSMENT

· Activity/Exercise- Patient walk three times a week

· Sleep/rest- Patient reports getting adequate sleep at night, 8 hrs. daily

· Nutrition/elimination-Patient reports eating well balanced diet and have a normal bowel movement

· Relationships/resources- Patient reports being married for 20yrs

· Spirituality- Patient reports being a Christian

· Coping and stress management- Patient report Nothing currently in her life that is stressful.

· Safety- Patient lives at home with her husband and two children, reports being safe

· Past Medical history -Asthma

· Past Surgical history – Patient report having C-Section when she had her kids.

· Psycho/Social history: Patient denies any drug use, EtOH, drugs, smoking, vaping.

· Family history- Patient reports Both parents are still living and very healthy

· Medications- Patient reports being?

· Allergies- Patient denies any known allergies

· Immunizations- Patient reports that all her immunization are up to dates

OBJECTIVE

Patient vital signs Vital Signs: Heart rate 78, blood pressure 134/70, respiratory rate 18. Patient is very nice and pleasant; she appears to look younger than her age. Clear Lungs sounds upon auscultation bilaterally. Normal S1 and S2, regular heart rate noted with rhythm, No Nuchal rigidity noted, Normocephalic. Neurologic: patient is alert and oriented to place, person, and time, and situation. Fluent English language with intact reading, comprehension, naming, and repetition. She was able to register and repeat 4 out of 4 words and recall 4 out of 5 at 5 minutes, 4 out of 4 with prompting. she was able to give accurate details of her remote and recent history. A very good historian as well. She was able to do serial 7s without challenges. She has no right/right confusion, apraxia, neglect or finger agnosia. Cranial Nerves: Patient’s Pupils are equal, round, and reactive to light. Her visual fields are intact to confrontation. Ocular movements are intact, Normal fundi. her face is symmetric and equal. Her hearing is intact to finger rub bilaterally. The tongue and palate muscle activate symmetrically. No dysarthria. her strength is full in trapezius and sternocleidomastoid bilaterally. Motor: patient has normal skin tone and bulk, 4/5 strength in all extremities secondary to Parkinson disease. No pronator drift noted. Reflexes: 1+ in the knees, 2+ in her upper extremities trace at the ankles. She has plantar response is flexor on both extremities. Sensory: she’s Intact to light touch, vibration bilaterally and pinprick. Coordination: Patient coordination was normal, No dysmetria on finger-nose-finger or heel-knee-shin. Normal rapid alternating movements. Fast finger tapping with normal amplitude and speed. Based on the full assessment, no bigger changes made to patient care plan however her Sinemet medication was increase to 25/100 mg 1-1/2 tablets to three times a day

DIAGNOSIS:

The patient diagnosed with idiopathic young-onset Parkinson disease with no new significant changes

PLAN:

· she seems to be doing very well on her medication regimen. We discuss more about her recent diagnosis with Parkinson, I encourage her continue with her daily exercise, and I will schedule her for a follow-up in six months.

· No abnormal findings noted.

· If patient has any Neurological changes or change in mental status, she must dial 911 or call the Nurse practitioner.

· Patients encourage to be active, eat a well-balanced diet, and get adequate sleep.

· Follow up for any other changes.

References

Dains, J. E., Baumann, L. C., & Scheibel, P. (2012). Advance health assessment and clinical

diagnosis in primary care. (4th ed.). St. Louis, MO: Elsevier.

Muhrer, Jill C. (2014). The importance of the history and physical in diagnosis. The Nurse

Practitioner: Volume 39-issue 4, P30-35. Retrieved on July 21st , 2020 from

https://journals.lww.com/tnpj/Fulltext/2014/04000/The_importance_of_the_history_and_physical_in.6.aspx

Johnson., J, Thompson. J. (1996). Rehabilitation in a neuroscience Centre: the role of expert

assessment and selection. British Journal of Therapy and Rehabilitation. 3(6):303-8.

Ackley, B. J., & Ladwig, G. B. (2010). Nursing diagnosis handbook: an evidence-based guide to

planning care (9th ed.). Maryland Heights, Mo.: Mosby.