Comprehensive SOAP Note #3
Number of sources: 4
Practicum Experience – Comprehensive SOAP Note #3
After completing this week’s Practicum Experience, review the Comprehensive SOAP Note Exemplar and Template in this week’s Resources, and reflect on a patient who presented with musculoskeletal disorders or pain. Describe the patient’s personal and medical history, drug therapy and treatments, and follow-up care.
All SOAP notes must be signed and each page must be initialed by your preceptor. When you submit your SOAP Notes, you should include the complete SOAP Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your SOAP Notes using SAFE ASSIGN.
Age 73 Male , J.S.
DX HTN, Arthritis,
Ambulate with cane
Vital signs 134/76 18 97.3 97% O2 SAT HT 5’6 217 WT
Pain medicine hydrocodone 5/325mg every 6 hours as needed for pain, pain level reported 3 after med relief and range 6to 8 on most days
Patient received flu immunization
No skin openings , poor turgor
Resp , no SOB lungs clear on asculation . Comprehensive SOAP Template
This template is for a full history and physical. For this course include only areas that are related to the case.
Patient Initials: _______ Age: _______ Gender: _______
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
A= associated signs and symptoms
E= exacerbating/relieving factors
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.
History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Medications: Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies: Include specific reactions to medications, foods, insects, and environmental factors. Identify if it is an allergy or intolerance.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations.
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and risky sexual behaviors.
Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
Immunization History: Include last Tdap, Flu, pneumonia, etc.
Significant Family History: Include history of parents, grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you so ensure that you include all essentials in your case (refer to Chapter 2 of the Sullivan text).
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P- only in this course. Do not use “WNL” or “normal.” You must describe what you see.
Vital signs: Include vital signs, ht, wt, and BMI.
General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of consciousness, and affect and reactions to people and things.
Peripheral Vascular: Abdomen:
Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.
ASSESSMENT: List your priority diagnosis (es). For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.
PLAN: Include additional laboratory and diagnostic tests, consults, therapeutic modalities, health promotion patient education as well as disposition/follow up instructions as they pertain to your patients’ assessment.
Treatment Plan: If applicable, include both pharmacological and non-pharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.
Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.
Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.
REFLECTION: Document what you learned from this experience? Any ah-ha’s?
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.
Preceptor Signature and Date
Signature is REQUIRED for this assignment.
Chief Complaint (CC): Musculoskeletal pain and arthritis.
History of Present Illness (HPI): J.S., a 73-year-old male, presents with a history of hypertension (HTN) and arthritis. The patient reports experiencing pain, with a current pain level of 3 on a scale of 0-10 after taking hydrocodone 5/325mg every 6 hours as needed. On most days, the pain ranges from 6 to 8. The patient’s mobility is impaired, requiring the use of a cane for ambulation. There are no skin openings, but the patient has poor turgor. The patient reports receiving a flu immunization and denies any allergies. Respiratory assessment reveals no shortness of breath, and lung auscultation is clear.
Hydrocodone 5/325mg: Every 6 hours as needed for pain.
No known allergies.
Past Medical History (PMH):
Flu immunization received.
Review of Systems:
General: No recent weight changes, weakness, fatigue, or fever.
HEENT: Not assessed.
Neck: Not assessed.
Respiratory: No shortness of breath, lungs clear on auscultation.
Cardiovascular/Peripheral Vascular: Not assessed.
Gastrointestinal: Not assessed.
Genitourinary: Not assessed.
Musculoskeletal: Musculoskeletal pain and arthritis.
Psychiatric: Not assessed.
Neurological: Not assessed.
Skin: No specific findings mentioned.
Hematologic: Not assessed.
Endocrine: Not assessed.
Allergic/Immunologic: Not assessed.
Vital signs: Blood pressure 134/76 mmHg, heart rate 18 bpm, oral temperature 97.3°F, oxygen saturation 97% on room air.
Weight: 217 lbs
General: Patient appears to be in pain, using a cane for ambulation.
Musculoskeletal: Impaired mobility, requiring a cane.
Priority Diagnosis: Musculoskeletal pain and arthritis.
Continue hydrocodone 5/325mg every 6 hours as needed for pain.
Physical therapy referral for pain management and improving mobility.
Schedule a follow-up appointment in two weeks to evaluate the effectiveness of the current treatment plan and adjust as necessary.
Encourage regular exercise within the patient’s abilities to improve strength and flexibility.
Discuss the importance of maintaining a healthy weight to reduce the stress on joints.
Educate the patient on proper body mechanics and techniques to prevent further injury and manage pain.
Ensure the patient is up to date with recommended immunizations for their age group, including Tdap and pneumonia vaccines.
During this experience, I learned the importance of a comprehensive assessment and management plan for patients with musculoskeletal disorders. I realized the significance of tailoring treatment plans to address the individual patient’s pain level, mobility, and specific needs. Collaborating with a physical therapist can be beneficial in providing holistic care and optimizing the patient’s outcomes. I also gained a deeper understanding of the impact of musculoskeletal disorders on a patient’s quality of life and the importance of promoting health behaviors to prevent further complications.