Question

Creating a SOAP note

For this discussion, you will be reviewing a patient progress note on Tana Smith. You will practice using your new medical vocabulary to create a SOAP note for a patient chart. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.

The “S" stands for subjective, which contains the signs and symptoms the patient complains about; such as “I am having severe headaches,” “I am hearing voices but do not see anyone,” or “I have pain in my back and numbness in my right leg.”

The “O” stands for objective, which contains information on what you observe, such as the vital signs: Temperature: 98.6, Pulse: 62, Respiration: 16, Weight: 155, Height 5’ 5,” Blood Pressure: 128/78. It can also be information such as: “Patient grimacing when palpating (touching) left lower quadrant of abdominal region” or “Patient gait is unsteady,” “Patient’s range of motion (ROM) in left arm is limited.” You can also document information on a urine sample obtained: “Urine is dark amber” or “blood noted, urine dipstick performed; results show trace blood and protein.”

I have included an example for your reference of documenting a SOAP note.

Example:

06/01/14: S: Pt presents with c/o (complaints of) pain in back. Pt states it is painful to urinate, and is making frequent trips to the bathroom. Pt states very little comes out and urine is dark. Pt is holding left upper lumbar region. Pt states the pain has been going on for the last 2 days. O: T: 100.9, P: 90, R: 24, W: 162, H: 5’ 9” BP: 130/90. Pt is alert and responsive x 3. Urine sample obtained. Dark amber in color, urine dipstick results: trace amounts of blood, and protein. A: Urinalysis results positive for E Coli. Diagnosis: UTI P: Broad spectrum antibiotic prescribed. Advised to avoid caffeine, drink plenty of water, and avoid sexual relations for duration of antibiotics. Follow-up in 2 days if s/s do not subside. – TThomas, RN, BSN

Now you are ready to get started. Review the progress note for Tana Smith below, which contains medical terminology, abbreviations, lab, and diagnostic information.

You are to respond by composing a SOAP note. Write your SOAP note in layman terms, which means you will need to decipher the medical information in the progress note. You will need to include at least two items from each of the areas: History, Objective Findings, and Assessment. In addition, you need to include a follow-up treatment plan after discharge to educate the patient on the diagnosis and prevention from further episodes.

PROGRESS NOTE

Main Street Medical Center

6000 North Tree Street – Branch PA 12345 Phone: (555) 123-4567

PATIENT NAME: Tana Smith MEDICAL RECORD: 8888888

DATE OF BIRTH: 12/10/1988 DATE OF VISIT: 1/15/2015

HISTORY: The patient is a 28-year-old female, who has a history of IUD placement in 2012. May of 2014, patient seen by a gynecologist for dysmenorrhea and menometrorrhagia. Upon examination a hysterosalpingogram was performed. Patient diagnosed with oophoritis and hematosalpinx with multiple myoma. In June of 2014, patient was scheduled for a salpingostomy laparoscopically. A hysteroscopy was performed with visualization of two myoma of the uterus on lower left wall approximately 3 cm and 2.5 cm in diameter. At the junction of the fundus and left salpingo, a 4 cm myoma was noted. A myomectomy was performed on the smaller myoma without incidence. A D and C was performed. Due to complications during the procedure, a left salpingo-oophorectomy was performed. Patient presents to the ER today with c/o myalgia, episodes of syncope, fever, rash of the face and chest, N and V x 2 days, and leukorrhea. Patient states she experienced dysmenorrhea for the last 5 days and diarrhea started today.

OBJECTIVE FINDINGS:

Vitals:	BP 105/62, T: 100.7, R: 22, P: 96, Weight: 155, Height: 5’6.”
Skin:	Facial erythroderma, warm, clammy .
Resp:	Lungs are clear to auscultation and percussion.
Cardio:	S1, S2 within normal limits, without gallops or murmurs.
Gastro:	abdominopelvic tender to palpation in lower right iliac region, without organomegaly mass.
Neuro:	LOC - Alert and oriented to person, but confused to time and place. Grips, flexion, extension weak but equal bilaterally. PERRL.
Urinary:	100 ml cloudy, amber urine. No dysuria, polyuria, or tenderness with voiding reported. No bladder distention reported.
Lab:	CBC, WBC, Creatinine, BUN, UA, Vaginal, Throat, and Urine cultures.

ASSESSMENT:

Patient posture is slightly bent; gait is slow. Examination conducted. Patient disoriented when asked questions, agitated and grimacing upon palpation of RLQ and posterior left lumbar region. Lower abdominopelvic region tender to palpation. No ascites noted. UA performed. Patient placed in lithotomy position to obtain vaginal cultures. Lab results show elevated WBCs – specific to elevated T Cells, anemia, albuminuria, and vaginal culture positive for staphylococci. This raises the suspicion of TSS and ARF.

TREATMENT SUMMARY: Patient admitted and transferred to the Intensive Care Unit, started on normal saline and Clindamycin 700 mg IV q 8h. Dopamine started IV. Indwelling Foley catheter inserted via urethra to monitor hourly output. Peri-pads used to replace tampons for menorrhea. VS taken q 2h. Day 2, patient responding well to intravenous infusion of dopamine and antibiotic therapy. Cultures obtained. Upon day 3, patient afebrile, blood pressure is within normal limits, cultures negative for Staph, BUN and liver function tests are within normal limits. Discharge orders written.

Please review the Discussion Board grading rubric on your Syllabus to understand how your posts will be evaluated. Your posts should be qualitative and provide substantive depth that advances the Discussion. You may view the Student Guide to Online Communication located in the Academic Tools tab above for additional information.

Initial Discussion responses should be around 150 words. Responses to your classmates or instructor should be around 75 words.

Answer 1

The history given should have specified the time gap between the D N C(Dilatation And Curettage) and presentation of present symptoms.

SOAP notes:

S: a 28-year-old female with history of IUD (Intra uterine device for prevention of conception) placement and a Dilatation And Curettage for the followed complications, presented today with episodes of body muscle pains and blackouts, fever, rash of the face and chest, nausea and vomitings for 2 days, and White discharge from vagina,pain in the lower abdomen for the last 5 days and loose stools since 1day

O:Blood Pressure: 105/62mmHg, Temperature: 100.7c, Respiratory rate: 22/min

Skin :Facial erythroderma, warm, clammy

Patient posture is slightly bent with slow gait. Patient was found to be disoriented , agitated and grimacing upon palpation of Right Lower Quadrant and posterior left lumbar region. Lower abdominopelvic region tender to palpation.

A:No ascites(fluid in the abdomen) noted. Ultrasound Abdomen performed showed normal result. Lab results show elevated White Blood Cells – specific to elevated T Cells, anemia, albuminuria, and vaginal culture positive for staphylococci. Diagnosis is Toxic Sock Syndrome with Acute Renal Failure.

P:

Follow up : Immediately to the Emergency/ casuality Department incase of syncope(blackouts),high ever, disorientation,passing less quantity of urine (<500ml)

If she feels better review after 3days for routine check up.

Advised to take bed rest till symptoms subside .Should not get up from lying or sitting position quickly as she may get blackout episodes.Avoid tampoons and use pads with frequent change at 4-5hours duration.Should rehydrate herself by taking lots of fluids- preferably homemade like soups,ready made oral rehydration solution, fruit juices.Prefer warm liquids and food to cold ones.Strictly avoid outside and canned foods.

Continue..

Tab.Clindamycin 300mg 1-1-1-1 for 3days

Tab. Domperidone 10mg 1-1-1 (till vomiting subsides )

Tab Paracetamol 500mg incase of temperature above 100degree celcius

History deciphered:

The patient is a 28-year-old female, who has a history of IUD(Intra Uterine Device to prevent pregnancy) placement in 2012. May of 2014, patient seen by a gynecologist for dysmenorrhea(lower abdominal pain during mensus) and menometrorrhagia(heavy bleeding during mensus). Upon examination a hysterosalpingogram(special type of X-ray used to see uterus and fallopian tube) was performed. Patient diagnosed with oophoritis(inflammation of ovary) and hematosalpinx(blood collection in the fallopian tube) with multiple myoma(cancer that forms in a type of white blood cell known as plasma cell). In June of 2014, patient was scheduled for a salpingostomy laparoscopically(creating a hole in the fallopian tube through a key hole opening through abdomen). A hysteroscopy(endoscopy of uterus) was performed with visualization of two myoma of the uterus(growth over the muscle of uterus) on lower left wall approximately 3 cm and 2.5 cm in diameter. At the junction of the fundus and left salpingo, a 4 cm myoma was noted. A myomectomy(removal of the growth) was performed on the smaller myoma without incidence. A D and C(dilatation and curettage) was performed.