Wk 9 episodic soap note

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3 APA References

PRAC 6541:
Primary Care of Adolescents and Children


Focused SOAP Checklist

SUBJECTIVE:

·
Chief Complaint: Did I state briefly in the patient’s own words

·
History of present illness: Did I write a paragraph in the order of the 7 attributes & did I put the 7 attributes in a concise list in the chart (OLD CART-if you don’t know it, please look it up)

·
Medications: did I list each medication and reason.

·
Allergies: Did I include specific reactions to medications, foods, and insects, environmental?

·
Past Medical History (PMH): Did I list all the patient
Illnesses, hospitalizations? Did I Include childhood illnesses

·
Past Surgical History (PSH): Did I list the
dates, indications and types of operations?

·
OB/GYN History: (if applicable) Obstetric history, menstrual history, methods of contraception and sexual function.

·
Personal/Social History: Tobacco use, Alcohol use, Drug use, risky sexual behavior. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits. Pediatrics: school status, parental smoking hx, birth history, school/daycare etc

·
Immunizations: Did I include
Last Tdap, Flu, pneumonia, etc. Pediatrics- (per pediatric schedule for age) HPV if applicable

·
Family History: Did I list for Parents, Grandparents, siblings, children?

·
Review of Systems (SUBJECTIVE DATA): Did I include the systems related to my Chief Complaint and chronic conditions? Did I type detailed description? I did NOT use WNL. I was specific in my descriptions (see health assessment textbook).
Did I remember this is what the patient says and not what I observed? Did I include the cardiovascular and respiratory system regardless of chief complaint?

Physical Exam: (OBJECTIVE DATA) This is what YOU see/touch/hear/smell

· Did I list the vital signs as the first thing in the objective section? Did I include the BMI for adults? Did I include the percentile for the ht, wt, bp etc for pediatrics?

· Did I examine the systems that are pertinent to the CC, HPI, and History. Did I describe what I observed? Did I never use WNL or normal? Did I describe what I observed during the physical exam?

· Did I include the systems in a list format?

· Did I include cardiovascular and respiratory systems regardless of cc?

· Did I delete the systems I did not review?

ASSESSMENT:

· Did I put my priority diagnosis in bold for EACH CC?

· Did I include at least 3 differentials(DD) after the priority diagnosis for EACH of my CC?

· Did I explain what each DD is, use references to explain and tell how you ruled in or ruled out each DD? (AND does your ROS and PE reflect this?)

· Did I include a reference citation for each diagnosis under the assessment area?

· Are my assessments concise and in a chart format?

· Did I put my differential diagnosis in order by priority?

· Did I provide a detailed rationale for each diagnosis?

Holistic care:

· Did I cover existing diagnoses and whether any changes need to be made?

· Did I include needed preventative care based on my patient’s age and risk factors?

PLAN:

· Did I include a treatment plan?

· Did I address if labs, x-rays, etc. were needed?

· Did I include a pharmacological plan and citation for EBP?

· Did I include non-pharmacological strategies?

· Did I discuss alternative therapies if applicable?

· Did I state when the patient needs a follow-up?

· Did I indication if any referrals or consultations were necessary or not necessary?

· Did I write a rationale based on evidence?

·
Health Promotion: Did I address this area? Did I state what the patient/ family need to do to promote their health based on the USPTF for adults or Bright Futures for children? Did I document my citations?

·
Disease Prevention: Did I do these based on recommendations from USPTF for adult’s or Bright Futures for children based on
the patient’s age? Did I state what needs to be done to detect disease early…fasting lipid profile, mammography, colonoscopy, immunizations, etc? Did I cite the source?

REFLECTION:

· Did I state what I learned from this experience?

· Did I state what I would you do differently or if I would do everything the same and the rationale?

· Did I state if I either agreed or disagreed with my preceptor
based on evidence (and cite references for EBP?

· Did I state what I would do if the person was insured versus if the person was not insured? Indicate how this would change your plan.

· Did I state the community resources in my area?

APA

· Do I have a minimum of 3 scholarly journal articles? (NONE OF WHICH ARE PATIENT EDUCATION SITES THAT I GOOGLED)

· Did I use at least 3-4 course resources?

· Do I have the paper in a neat format?

· Did I list my references in APA format?

Developed by Joyce Turner, NP. Revision 2/22/17 by Nancy Hadley, DNP, APRN, FNP-BC

© 2020 Walden University 1

Patient is a 16-year-old Caucasian female who presents to the clinic with complaints of a stomachache for the past several weeks. The aches worsen with hunger and are relieved with eating. She rates her pain a 8/10. Her last period was three months ago, and she has a positive urine pregnancy test. She reports sleeping problems, fear, and anxiety. She also lives with her aunt and uncle who are her legal guardians as she was removed from her mother for drug use and drugs being found in the home. When discussing her feelings about her mother’s boyfriend she becomes tearful and doesn’t want to talk much about him. She states, “she does not want this baby in her” and doesn’t want her aunt and uncle to find out.

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