Episodic SOAP Note Assignment for NURS 6512 Week 9 Case Study 3 Drooping of Face in a 33-Year-Old Female Patient

Create an episodic focused SOAP note using the assigned case study of a 33-year-old female with sudden right-sided facial drooping excessive tearing and drooling to document neurological symptoms accurately.

MY ASSIGNED CASE

CASE STUDY 3: Drooping of Face

A 33-year-old female comes to your clinic alarmed about sudden “drooping” on the right side of the face that began this morning. Patients often feel anxious when noticing these changes unexpectedly. She complains of excessive tearing and drooling on her right side as well.

Such symptoms can affect daily activities like eating or speaking.

Using the Episodic/Focused SOAP Template:

• Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned.

Nurses use this structured approach to organize patient information clearly.

• Provide evidence from the literature to support diagnostic tests that would be appropriate for your case.

Grading Rubric Excerpt for SOAP Note and Evidence

Excellent 45 (45%) – 50 (50%)
The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.

Meeting these criteria helps ensure high-quality clinical documentation.

Good 39 (39%) – 44 (44%)
The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.

Fair 33 (33%) – 38 (38%)
The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected.

Poor 0 (0%) – 32 (32%)
The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.

• List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

Considering multiple options rules out serious causes effectively.

Grading Rubric Excerpt for Differential Diagnosis

Excellent 30 (30%) – 35 (35%)
The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study and provides a thorough, accurate, and detailed justification for each of the five conditions selected.

Good 24 (24%) – 29 (29%)
The response lists four to five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected.

Fair 18 (18%) – 23 (23%)
The response lists three to four possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or some inaccuracy in the conditions and/or justification for each.

Poor 0 (0%) – 17 (17%)
The response lists three or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.

Written Expression and Formatting – Paragraph Development and Organization:

Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

Strong writing skills enhance professional communication in healthcare.

Additional Rubric Categories

Excellent 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

Good 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

Fair 3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.

Poor 0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

Written Expression and Formatting – English writing standards:

Correct grammar, mechanics, and proper punctuation–

Attention to these details reflects professionalism.

Excellent 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.

Good 4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors.

Fair 3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.

Poor 0 (0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.–

Excellent 5 (5%) – 5 (5%)
Uses correct APA format with no errors.

Good 4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors.

Fair 3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors.

Poor 0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors.

Total Points: 100
Name: NURS_6512_Week_9_Assignment1_Rubric

Assignment 1: Case Study Assignment: Assessing Neurological Symptoms

Photo Credit: Getty Images/iStockphoto

Imagine not being able to form new memories. This is the reality patients with anterograde amnesia face. Although this form of amnesia is rare, it can result from severe brain trauma. Anterograde amnesia demonstrates just how impactful brain disorders can be to a patient’s quality of living. Accurately assessing neurological symptoms is a complex process that involves the analysis of many factors.

Early intervention often improves outcomes significantly.

In this Case Study Assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

To Prepare

By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.

Instructors provide these assignments to match learning objectives.

Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

Templates standardize documentation across healthcare settings.

With regard to the case study you were assigned:

• Review this week’s Learning Resources, and consider the insights they provide about the case study.

These resources build foundational knowledge for clinical practice.

• Consider what history would be necessary to collect from the patient in the case study you were assigned.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

Detailed history and targeted exams guide effective testing.

• Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

The Case Study Assignment

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

Submitting complete work by the deadline supports academic success.

By Day 6 of Week 9

Submit your Assignment.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

Please save your Assignment using the naming convention “WK9Assgn1+last name+first initial.(extension)” as the name.

Click the Week 9 Assignment 1 Rubric to review the Grading Criteria for the Assignment.

Click the Week 9 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.

Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK9Assgn1+last name+first initial.(extension)” and click Open.

If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.

Click on the Submit button to complete your submission.

Accurate neurological assessments like this episodic SOAP note for facial drooping help differentiate conditions such as Bell’s palsy from stroke or infections. Using evidence-based diagnostic tests and building a strong differential diagnosis improves patient care in advanced practice nursing. Mastering the SOAP format with literature support prepares nurses for real-world clinical documentation and decision-making.

Create an episodic/focused SOAP note for the NURS 6512 Week 9 case study of a 33-year-old female with sudden right-sided facial drooping, excessive tearing, and drooling; provide literature evidence for diagnostic tests and list five justified differential diagnoses following the rubric.

References / Learning Resources

1. Heckmann, J. G., Urban, P. P., Pitz, S., Guntinas-Lichius, O., & Gágyor, I. (2019). The diagnosis and treatment of idiopathic facial paresis (Bell’s palsy). Deutsches Ärzteblatt International, 116(41), 692–702. https://doi.org/10.3238/arztebl.2019.0692
2. Zimmermann, J., Jesse, S., Kassubek, J., Pinkhardt, E., & Ludolph, A. C. (2019). Differential diagnosis of peripheral facial nerve palsy: A retrospective clinical, MRI and CSF-based study. Journal of Neurology, 266(10), 2488–2494. https://doi.org/10.1007/s00415-019-09387-w
3. Kim, S. J., & Lee, H. Y. (2020). Acute peripheral facial palsy: Recent guidelines and a systematic review of the literature. Journal of Korean Medical Science, 35(30), e245. https://doi.org/10.3346/jkms.2020.35.e245
4. Gardner, S., Garber, L., & Grossi, J. (2025). Bell’s palsy: Description, diagnosis, and current management. Cureus, 17(1), e77656. https://doi.org/10.7759/cureus.77656
5. Dalrymple, S. N., Row, J. H., & Gazewood, J. D. (2025). Bell palsy. Primary Care: Clinics in Office Practice, 52(1), 111–121. https://doi.org/10.1016/j.pop.2024.09.012