You are going to create a soap note about this patient here: D.W is a 29-year-old G2P1 female presents to the clinic with complaints of sharp, intermittent lower abdominal pain on the right side that started three days ago. She reports that the pain has gradually worsened and is now constant, radiating to her lower back. She also notes light vaginal spotting, which she initially thought was an irregular period, but it has continued for several days. The patient states that she has been feeling lightheaded and nauseous since this morning. Her last menstrual period (LMP) was six weeks ago, and she has a history of irregular cycles. She had a positive home pregnancy test one week ago but has not yet had her first prenatal visit. She denies passing clots, fever, chills, dysuria, or recent infections.
Her past obstetric history includes one prior full-term vaginal delivery without complications. She has no known history of sexually transmitted infections (STIs), pelvic inflammatory disease (PID), or previous ectopic pregnancy. However, she does report a prior laparoscopic appendectomy at age 22. The patient is sexually active in a monogamous relationship and has not been using contraception.
On physical examination, she appears slightly pale and uncomfortable but is alert and oriented. Her vital signs show mild tachycardia (HR: 102 bpm), normal blood pressure (110/70 mmHg), and normal temperature (98.6°F). A pelvic examination reveals mild cervical motion tenderness, significant right adnexal tenderness, and a slightly enlarged uterus. No significant vaginal bleeding is observed. I am attaching the template so you can develop one. In addition to that I am attaching my previous one so you can understand about the references and in text citations and per reviewed rationales. Instructions:
nstructions:
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
S =Subjective data: Patient’s Chief Complaint (CC).O =Objective data: Including client behavior, physical assessment, vital signs, and meds.A =Assessment: Diagnosis of the patient’s condition. Include differential diagnosis.P =Plan: Treatment, diagnostic testing, and follow up . SOAP starts Begins with patient initials, age, race, ethnicity and gender (5 demographics)
Chief Complaint (Reason for seeking health care)
4 to >3 pts
Includes a direct quote from patient about presenting problem
History of the Present Illness (HPI)
5 to >3 pts
Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)
Allergies
2 to >1.5 pts
Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)
Review of Systems (ROS)
15 to >8 pts
Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to chief complaint AND uses the words “admits” and “denies”
Vital Signs
2 to >1.5 pts
Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)
Labs
2 to >1.5 pts
Includes a list of the labs reviewed at the visit, values of lab results and highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed.
Medications
4 to >2 pts
Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)
Past Medical History
3 to >2 pts
Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current
Past Surgical History
3 to >2 pts
Includes, for each surgical procedure, the year of procedure and the indication for the procedure
Family History
3 to >2 pts
Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.
Social History
3 to >2 pts
Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.
Health Maintenance / Screenings
3 to >2 pts
Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests
Physical Examination
15 to >8 pts
Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint
Diagnosis
5 to >3 pts
Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority) with in text citation
Differential Diagnosis
5 to >3 pts
Includes at least 3 differential diagnoses for the principal diagnosis with in text citations
ICD 10 Coding
3 to >2 pts
Correctly includes all ICD-10 codes relevant to the diagnoses addressed at the visit
Pharmacologic treatment plan
5 to >3 pts
Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. AL L with in text citations- references.
Diagnostic / Lab Testing
3 to >2 pts
Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”
Education
3 to >2 pts
Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives.
Anticipatory Guidance
3 to >2 pts
Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening)) all with in text citations and references
Follow Up Plan
2 to >1 pts
Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)
Prescription
3 to >2 pts
Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials
Writing Mechanics, Citations, and APA Style
3 to >2 pts
Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors. Include at least 6 References.