problem focused soap note 682 wk4

FNP SOAP Note Template

Use this template for Comprehensive Notes (H&Ps) and Problem-Focused Notes (Episodic/progress notes). For the Problem-Focused Notes,

only
include pertinent problem-focused information related to the chief concern (CC).

Demographic Data

· Patient age and gender identity

· MUST BE HIPAA compliant

Subjective

Chief Complaint (CC)

· Place the complaint in Quotes

· Brief description -only a few words and in the patient’s words … “My chest hurts,” “I cannot breath,” or “I passed out,” etc.

History of Present Illness (HPI) – the
reason for the appointment today

· Use the OLD CARTS acronym to document the eight elements of a chief concern (CC): Onset, Location/radiation, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity)

· Briefly describe the general state of health prior to the problem.

· Are Activities of Daily Living (ADL) impacted by the current problem?

Past Medical History:

· List current and past medical diagnoses

Past Surgical History:

· List all past surgeries

FAMILY HISTORY:

· Include medical/psychiatric problems to include 3 generations (parents, grandparents, siblings, or
direct relatives.

Current Medications:

· Include current prescription(s), over-the-counter medications, herbal/alternative medications as well as vitamin/supplement use.

ALLERGIES: Include medications, foods, and chemicals such as latex.

Immunizations History: list current immunization status and address deficiency

Preventative health History: (See Table below – Appendix A)

SOCIAL HISTORY:

·
Include nutrition, exercise, substance use (details of use: caffeine, EtOH, illicit drug use), sexual history/preference, financial problems, legal issues, kids, and history of abuse, including sexual, emotional, or physical.

·
Employment/Education: occupation (type), exposure to harmful agents, highest school achievement

REVIEW OF SYSTEMS:

· A ROS is a question-seeking inventory by body systems to identify signs and/or symptoms that the patient may be experiencing or has experienced that may or may not correlate with the CC.

*If a + finding is found not related to the cc this may represent an additional problem that will need to be detailed in the HPI.

· Must include any physical complaint(s) by the body system that is relevant to the treatment and management of the current concern(s).
List only the pertinent body systems specific to the CC.

·
Remember to include pertinent positive and negative findings when detailing the ROS related to a chief concern (cc).

·
Do not repeat the information provided in HPI

· Use the format below when detailing the ROS

ROS:

General:

Eyes:

Ears, nose, mouth & throat:

Cardiovascular:

Respiratory:

Gastrointestinal:

Skin & Breasts:

Musculoskeletal:

Allergic:

Immunologic:

Endocrine:

Hematopoietic/Lymphatic:

Genitourinary:

Neurological:

Psychiatric/Mental Status:

Objective

PHYSICAL EXAMINATION:

VITAL SIGNS: Blood pressure. Heart rate (regular or irregular). Respirations. SaO2 (on room air or O2). Temperature. Weight. Height.

*Document the presence of any internal/external devices (IV, Central lines, NGTs, G-tubes, Ostomies, urinary catheters) and dates of placement.

General:

Eyes:

Ears, nose, mouth & throat:

Cardiovascular:

Respiratory:

Gastrointestinal:

Skin & Breasts:

Musculoskeletal:

Allergic:

Immunologic:

Endocrine:

Hematopoietic/Lymphatic:

Genitourinary:

Neurological:

Psychiatric/Mental Status:

Pertinent Diagnostic Test Results:

Assessment (Diagnosis)

Differential Diagnosis (DDx)

· Include two (2) differential diagnoses you considered but did not select as the final diagnosis. Why were these 2 diagnoses not selected? Support with pertinent positive and negative findings for each differential with an evidence-based guideline(s) (required).

Working or Final Diagnosis:

· Final or working diagnosis (1) (including ICD-10 code)

· Provide a rational explanation supported by evidenced-based guidelines (required). List the pertinent positive and negative symptoms/signs that support your final diagnosis.

Plan

Treatment (Tx) Plan: pharmacologic and/or nonpharmacologic

· Pharmacologic -include full prescribing information for each medication(s) ordered

· Refill Provided: Include full prescribing information for each medication(s) refilled and the correlating diagnosis related to the refill.

Patient Education:

· Include specific education related to each medication prescribed.

· Was risk versus benefit of current treatment plan addressed for medication(s) and interventions? Was the patient included in the medical decision making and in agreement with the final plan

· NPs should not be prescribing non-FDA approved medications or medications related to off-label use. If a physician prescribed a non-FDA-approved medication for working diagnosis or recommended off-label use was education provided and was the risk to benefit of the medication(s) addressed in the patient’s education?

Prognosis Good, Fair, or Poor?

· Indicate the patient’s prognosis: Good, Fair, Poor

· Provide support for your selected prognosis

Referral/Follow-up

· Did you recommend follow-up with PCP, or other healthcare professionals?

· When is the subsequent follow-up?

Disposition:

· Indicate the disposition of the patient.

· Was the patient sent home, Emergency room via EMS, etc.

· Include rationale for the follow-up recommendation or referral

Reference(s)

· Include APA formatted references for written assignments.

· Minimum 2 references are required from evidence-based resources.

· Oral assignments should include verbally articulated evidence-based guideline(s) used to prepare the oral presentation.

APPENDIX A

PREVENTATIVE CARE SCHEDULE (Example – not all-inclusive)

Preventive Care	Date	Result	Referrals Made
Pap
Mammogram
A1C
Eye Exam
Monofilament Test
Urine Microalbumin
Diet/Lifestyle Modifications
Digital Rectal Exam (DRE)
PSA
Colonoscopy or FOBT
Dexa Scan
CXR
BNP
ECG
Echo
Stress Test
Vaccines