Gender

NURS_6512_comprehensiveSOAPTemplate

Comprehensive SOAP TemplateThis template is for a full history and physical. For this course include only areas that are related to the case.Patient Initials: _______     Age: _______                       Gender: _______Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.L =locationO= onset C= characterA= associated signs and symptomsT= timingE= exacerbating/relieving factorsS= severitySUBJECTIVE DATA: Include what the patient tells you, but organize the information.Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.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 (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:Location: headOnset: 3 days agoCharacter: pounding, pressure around the eyes and templesAssociated signs and symptoms: nausea, vomiting, photophobia, phonophobiaTiming: after being on the computer all day at workExacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely betterSeverity: 7/10 pain scaleMedications: 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. Identify if it is an allergy or intolerance.Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations. Past Surgical History (PSH): Include dates, indications, and types of operations.Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and risky sexual behaviors.Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.Immunization History: Includelast 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 and sexual preference.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 so ensure that you include all essentials in your case (refer to Chapter 2 of the Sullivan text).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:  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 unless you are doing a total H&P- only in this course. Do not use “WNL” or “normal.” You must describe what you see.Physical Exam:Vital signs: Include vital signs, ht, wt, 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 consciousness, and affect and reactions to people and things. HEENT:Neck:ChestLungs: HeartPeripheral Vascular: Abdomen:Genital/Rectal:Musculoskeletal:Neurological:Skin:Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.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. 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: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.REFLECTION: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. 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?

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