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Posted: November 14th, 2022

SOAP Note Write Up for VR Patient Angela Atwater

SOAP Note Write Up for VR Patient Angela Atwater

This assignment will demonstrate your ability to provide age-appropriate anticipatory guidance while recognizing the need to refer patients that are outside of the scope of practice of the family nurse practitioner. This will be demonstrated by completing a SOAP note based on a patient Angela Atwater seen in Unit 2 in the VR platform.

Write-ups

The SOAP note serves several purposes:

It is an important reference document that provides concise information about a patient’s history and exam findings at the time of patient visit.
It outlines a plan for addressing the issues which prompted the office visit. This information should be presented in a logical fashion that prominently features all of the data that’s immediately relevant to the patient’s condition.
It is a means of communicating information to all providers who are involved in the care of a particular patient. It outlines a strategy for dealing with the issues that prompted the office visit. This information should be presented logically, with a focus on all data that is immediately relevant to the patient’s condition.
It is a method of communicating information to all providers involved in a specific patient’s care.
It allows the NP student an opportunity to demonstrate their ability to accumulate historical and examination-based information, make use of their medical knowledge, and derive a logical plan of care.
Knowing what to include and what to leave out will be largely dependent on experience and your understanding of illness and pathophysiology. If, for example, you were unaware that chest pain is commonly associated with coronary artery disease, you would be unlikely to mention other coronary risk-factors when writing the history. As you gain experience, your write-ups will become increasingly focused. You can accelerate the process by actively seeking feedback about all the SOAP notes that you create, as well as by reading those written by more experienced practitioners.

The core aspects of the SOAP note are described in detail below.

For ease of learning, a SOAP Note Template has been provided. For this assignment, proper citation and referencing is required because this is an academic paper.

S: Subjective information. Everything the patient tells you. This includes several areas including the chief complaint (CC), the history of present illness (HPI), medical history, surgical history, family history, social history, medications, allergies, and other information gathered from the patient. A commonly used mnemonic to explore the core elements of the history of present illness (HPI) is OLD CARTS, which includes: Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatments, and Severity.

O: Objective is what you see, hear, feel or smell. Your physical exam including vital signs.

A: Assessment/ Your differentials

P: Plan of care including health promotion and disease prevention for the patient related to their age and gender.

If there are any questions, please contact your instructor.

DUE: to the Journal Dropbox by end of the unit week, end of day (EOD) Tuesday.

To view the Grading Rubric for this assignment, please visit the Grading Rubrics section of Course Resources.

Writing Guide:
S:
Subjective:

CC: Patient presents with complaints of fatigue, difficulty sleeping, and headaches for the past two weeks.
HPI: Onset of symptoms began gradually two weeks ago. Location of symptoms is primarily in the head and fatigue is throughout the body. Symptoms have been continuous and have not been relieved by any treatments tried thus far. Characteristics of the headaches include a dull, constant ache. No specific aggravating or relieving factors have been identified. The patient reports no recent changes in medication or allergies.
Medical history: Patient reports a history of hypertension and mild asthma, both of which are well-controlled with medication.
Surgical history: Patient has no history of surgery.
Family history: Patient reports a family history of hypertension and migraines.
Social history: Patient is a 35-year-old female who works as a teacher. She reports moderate stress levels due to work and family responsibilities. She denies any recent changes in her stress levels.
O:
Objective:

Vital signs: BP: 128/82 mmHg, HR: 72 bpm, RR: 16 bpm, Temp: 98.6 F
Physical exam: Patient appears tired and reports a headache during the exam. Neurological exam is within normal limits.
A:
Assessment:

Differentials include tension headache, migraines, and sleep disturbance.
P:
Plan:

Recommend patient follow up with primary care provider to further evaluate and rule out any underlying medical conditions.
Encourage patient to maintain a consistent sleep schedule and establish a relaxing bedtime routine.
Advise patient to engage in stress-reducing activities such as exercise and meditation.
Provide patient with education on headache management techniques, including over-the-counter pain medication and relaxation techniques.
Discuss options for preventative medication for migraines with primary care provider.
Implement health promotion and disease prevention strategies for hypertension and asthma, including adherence to medication regimen, diet and exercise recommendations and regular follow up with primary care provider.

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