Pregnant patient with Hypertension
Select a patient that you examined during the last three weeks. With this patient in mind, address the following in a SOAP Note:
â€¢Subjective: What details did the patient provide regarding her personal and medical history?
â€¢Objective: What observations did you make during the physical assessment?
â€¢Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
â€¢Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
â€¢Reflection notes: What would you do differently in a similar patient evaluation?
SOAP Note Evaluation Criteria
Each SOAP Note is worth 100 points. The original grading criteria has been modified to make it clear how points would be allocated. The point allocation for each major category was not altered.
SOAP Notes should reflect new experiences related to your practicum experiences in this course. Your submissions should be your original work and cannot be repurposed from previous courses.
Your SOAP Note should be based on an individual patient and address the following:
â€¢ Subjective: Details the patient provided regarding his or her personal and medical history (15 points)
â€¢ How points will be allocated
â€¢ CC (1 point)
â€¢ Pertinent positives (OLDCARTS) (5 points)
â€¢ Pertinent negatives (from ROS) (5 points)
â€¢ Pertinent PMH, SH, and FH (3 points)
â€¢ Medications and drug/food allergies are not included (1 point)
â€¢ Objective: Observations that you make during the physical assessment (15 points)
â€¢ How points will be allocated
â€¢ VS including BMI (2 points)
â€¢ Heart and lungs (1 point)
â€¢ Systems or specialty exam techniques that are not necessary to arrive at a diagnosis are included. (-1 for each up to 5 points)
â€¢ Systems or specialty exam techniques that are necessary to arrive at your diagnosis are omitted. (-1 for each up to 5 points)
â€¢ Diagnostic test results (2 point)s
â€¢ Assessment: Need to list your priority diagnosis first. For each priority diagnosis, if possible list at least 3 differential diagnoses. Focus on the â€œhorsesâ€ first, then â€œzebrasâ€. Support your selection with rationales keeping in mind the likelihood of each subsequent diagnosis based on the patientâ€™s age, gender, and race, risk factors, lifestyle choices, and co-morbidities. (30 points â€“ 10 points for each priority diagnosis. If less than 3 are appropriate to include â€“ simply no other diagnoses to consider â€“ you will receive all 30 points. Please do not â€œstretchâ€ to find 3 if they are not actual possibilities.
â€¢ Plan: Your plan for diagnostics and primary diagnosis; and your plan for treatment and management including alternative therapies. (15 points)
Because not all items listed below may be appropriate for your plan, if you include what is appropriate, you will receive the points. However, if one of the items that should have been included was not, points associated with each item will be deducted.
â€¢ Pharmacological and non-pharmacological strategies
â€¢ Medications discontinued (â€œd/c lisinopril 10 mg dailyâ€) (1 point)
â€¢ Medications started (â€œstart Avapro 150 mg dailyâ€) (2 points)
â€¢ Alternative therapies if appropriate (1 point)
â€¢ Health Promotion strategies â€“ patient/family education (3 points)
â€¢ Disease Prevention strategies with timeframe if appropriate (3 points)
â€¢ Diagnostic tests ordered with timeframe (now, in 2 weeks, prior to f/u visit in 3 months) (3 points)
â€¢ Referrals or consultations if appropriate (1 point)
â€¢ Follow-up interval (1 point)
â€¢ Reflection notes: What you would do differently in a similar patient evaluation (25 points)
Address each point even if you have nothing specific to add. For example, if you would have done nothing differently, say so and include why. If you fail to mention one of these items, you will lose the points associated with it.
â€¢ What did you learn from this experience? Any ah-haâ€™s? (5 points)
â€¢ What would you do differently? (5 points)
â€¢ What additional data would you have gathered? (5 points)
â€¢ What additional elements of the exam would you have done? (5 points)
â€¢ Do you agree with your preceptor based on the evidence? (5 points)
Sources of support for your analysis may include your Learning Resources (texts, articles, videos), but should also include evidence-based information from national guidelines or journal articles in nursing and other professional literature. Use these sources to support the observations and conclusions that you reach, and cite them in the appropriate place in your SOAP Note. Include a minimum of two peer-reviewed journal articles along with other sources. The goal is to analyze what you observed and relate it to evidence-based practice.
Formatting: It is understood that you will be using incomplete sentences in the actual SOAP note. However, please use punctuation effectively, using a semi-colon or period to alert the reader that you are changing topics. Your assessment and plan should maintain the SOAP format. References in APA format must be included for items in the plan. Points may be deducted if this does not occur.
SOAP note rubric
Subjective (15 points)
â€¢ CC 1
â€¢ Pertinent positives (OLDCARTS) 5
â€¢ Pertinent negatives (from ROS) 5
â€¢ Pertinent PMH, SH, and FH 3
â€¢ Medications and drug/food allergies are not included 1
Objective (15 points)
â€¢ VS including BMI 2
â€¢ Heart and lungs 1
â€¢ Systems or specialty exam techniques that are not necessary to arrive at a diagnosis are included. -5
â€¢ Systems or specialty exam techniques that are necessary to arrive at your diagnosis are omitted. -5
â€¢ Diagnostic test results 2
Assessment â€“ 10 points for each priority diagnosis (total 30 points)
Plan (15 points)
â€¢ Medications discontinued (â€œd/c lisinopril 10 mg dailyâ€) 1
â€¢ Medications started (â€œstart Avapro 150 mg dailyâ€) 2
â€¢ Alternative therapies if appropriate (1 point) 1
â€¢ Health Promotion strategies â€“ patient/family education 3
â€¢ Disease Prevention strategies with timeframe if appropriate 3
â€¢ Diagnostic tests ordered with timeframe (now, in 2 weeks, prior to f/u visit in 3 months) 3
â€¢ Referrals or consultations if appropriate 1
â€¢ Follow-up interval 1
Reflection notes (25 points)
â€¢ What did you learn from this experience? Any ah-haâ€™s? (5 points) 5
â€¢ What would you do differently? 5
â€¢ What additional data would you have gathered? 5
â€¢ What additional elements of the exam would you have done? 5
â€¢ Do you agree with your preceptor based on the evidence? 5
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