Pneumonia Soap Note Acute Conditions Paper.pdf

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1. Pneumonia Soap Note Acute Conditions Paper
Pneumonia Soap Note Acute Conditions PaperPneumonia Soap Note Acute Conditions
PaperFollow the MRU Soap Note Rubric as a guide:Use APA format and must include mia
minimum of 2 Scholarly Citations.Soap notes will be uploaded to Moodle and put through
TURN-It-In (anti-Plagiarism program)Turn it in’ s Score must be less than 25% or will not
be accepted for credit; it must be your own work and in your own words. You can resubmit,
Final submission will be accepted if less than 25%. Copy-paste from websites or textbooks
will not be accepted or tolerated and will receive a grade of 0 (zero) with no resubmissions
allowed.Please see College Handbook regarding Academic Misconduct Statement.Must use
the sample templates for your soap note. Keep this template for when you start
clinicals.undefinedThe use of templates is ok with regards to Turn it in, but the Patient
History, CC, HPI, Assessment, and Plan should be of your own work and individualized to
your made-up patient.ORDER NOW FOR CUSTOMIZED, PLAGIARISM-FREE PAPERSThis
sheet is to help you understand what we are looking for, and what our margin remarks
might be about on your write ups of patients. Since at all of the white-ups that you hand in
are uniform, this represents what MUST be included in every write-up. 1) Identifying Data
(___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The
patient complaint should be given in quotes. If the patient has more than one complaint,
each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective
and under the appropriate number. 2) Subjective Data (___30pts.): This is the historical part
of the note. It contains the following: a) Symptom analysis/HPI(Location, quality , quantity
or severity, timing, setting, factors that make it better or worse, and associate
manifestations.(10pts). b) Review of systems of associated systems, reporting all pertinent
positives and negatives (10pts). c) Any PMH, family hx, social hx, allergies, medications
related to the complaint/problem (10pts). If more than one chief complaint, each should be
written u in this manner. 3) Objective Data(__25pt.): Vital signs need to be present. Height
and Weight should be included where appropriate. a) b) c) Appropriate systems are
examined, listed in the note and consistent with those identified in 2b.(10pts). Pertinent
positives and negatives must be documented for each relevant system. Any abnormalities
must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using
“ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe
things. (5pts). 4) Pneumonia Soap Note Acute Conditions PaperAssessment (___10pts.):
Encounter paragraph and diagnoses should be clearly listed and worded appropriately
including ICD10 codes. 5) Plan (___15pts.): Be sure to include any teaching, health

2. maintenance and counseling along with the pharmacological and non-pharmacological
measures. If you have more than one diagnosis, it is helpful to have this section divided into
separate numbered sections. 6) Subjective/ Objective, Assessment and Management and
Consistent (___10pts.): Does the note the appropriate differential diagnosis process? Is
there evidence that you know what systems and what symptoms go with which complaints?
The assessment/diagnoses should be consistent with the subjective section and then the
assessment and plan. The management should be consistent with the assessment/
diagnoses identified. 7) Clarity of the Write-up(___5pts.): Is it literate, organized and
complete? Comments: Total Score: ____________ Instructor: __________________________________
Guidelines for Focused SOAP Notes · Label each section of the SOAP note (each body part
and system). · Do not use unnecessary words or complete sentences. · Use Standard
Abbreviations S: SUBJECTIVE DATA (information the patient/caregiver tells you). Chief
Complaint (CC): a statement describing the patient’s symptoms, problems, condition,
diagnosis, physician-recommended return(s) for this patient visit. The patient’s own words
should be in quotes. History of present illness (HPI): a chronological description of the
development of the patient’s chief complaint from the first symptom or from the previous
encounter to the present. Include the eight variables (Onset, Location, Duration,
Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or
an update on health status since the last patient encounter. Past Medical History (PMH):
Update current medications, allergies, prior illnesses and injuries, operations and
hospitalizations allergies, age-appropriate immunization status. Family History (FH):
Update significant medical information about the patient’s family (parents, siblings, and
children). Include specific diseases related to problems identified in CC, HPI or ROS. Social
History(SH): An age-appropriate review of significant activities that may include
information such as marital status, living arrangements, occupation, history of use of drugs,
alcohol or tobacco, extent of education and sexual history. Pneumonia Soap Note Acute
Conditions PaperReview of Systems (ROS). There are 14 systems for review. List positive
findings and pertinent negatives in systems directly related to the systems identified in the
CC and symptoms which have occurred since last visit; (1) constitutional symptoms (e.g.,
fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5)
respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9}.integument
(skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13)
hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE
findings section. 0: OBJECTIVE DATA (information you observe, assessment findings, lab
results). Sufficient physical exam should be performed to evaluate areas suggested by the
history and patient’s progress since last visit. Document specific abnormal and relevant
negative findings. Abnormal or unexpected findings should be described. You should
include only the information which was provided in the case study, do not include
additional data. Record observations for the following systems if applicable to this patient
encounter (there are 12 possible systems for examination): Constitutional (e.g. vita! signs,
general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU,
Musculoskeletal, Skin, Neurological, Psychiatric,
Hematological/lymphatic/immunologic/lab testing. The focused PE should only include

3. systems for which you have been given data. NOTE: Cardiovascular and Respiratory
systems should be assessed on every patient regardless of the chief complaint. Testing
Results: Results of any diagnostic or lab testing ordered during that patient visit. A:
ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code) List and
number the possible diagnoses (problems) you have identified. These diagnoses are the
conclusions you have drawn from the subjective and objective data. Remember: Your
subjective and objective data should your diagnoses and your therapeutic plan. Do not
write that a diagnosis is to be “ruled out” rather state the working definitions of each
differential or primary diagnosis (es). For each diagnoses provide a cited rationale for
choosing this diagnosis. Pneumonia Soap Note Acute Conditions PaperThis rationale
includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the
common signs and symptoms, the patients presenting signs and symptoms and the focused
PE findings and tests results that the dx. Include the interpretation of all lab data given in
the case study and explain how those results your chosen diagnosis. P: PLAN (this is your
treatment plan specific to this patient). Each step of your plan must include an EBP citation.
1. Medications write out the prescription including dispensing information and provide EBP
to ordering each medication. Be sure to include both prescription and OTC medications. 2.
Additional diagnostic tests include EBP citations to ordering additional tests 3. Education
this is part of the chart and should be brief, this is not a patient education sheet and needs to
have a reference. 4. Referrals include citations to a referral 5. Follow up. Patient follow-up
should be specified with time or circumstances of return. You must provide a reference for
your decision on when to follow up. (Student Name) Miami Regional University Date of
Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. David Trabanco DNP, APRN,
AGNP-C, FNP-C Soap Note # ____ Main Diagnosis: Pneumonia PATIENT INFORMATION
Name: LK Age: 60 Gender at Birth: Male Gender Identity: Male Source: patient Allergies:
None reported Current Medications: ? A25mg of HCTZ ? Albuterol and 20mg Simvastatin
per day PMH: • COPD Immunizations: Fully updated Preventive Care: Talking nature walk
three times a week. Surgical History: Cholecystectomy (2001) Family History: LK stays with
his wife and their three children in a well-furnished and safe house. His parents died when
he was a teenager. His mother died of diabetes and hypertension, while his father died of
hypertension and heart attack. His wife and children are healthy with no major health
issues or complications. Social History: The confirms that he has been smoking for about ten
years. His smoking habit increased, and he used to smoke one pack of cigarettes every day.
He stopped cigarette smoking three years ago. The patient confirms that he drunk alcohol
last year for five months, but he stopped. The patient denies the use of illicit drugs or
substances of abuse. Sexual Orientation: Straight Nutrition History: Non-contributory
Subjective Data: Chief Complaint: “I have been experiencing fatigue, shortness of breath,
fever, and dry cough, which have worsened in the past week.” “I have been unable to engage
in strenuous physical tasks or carry out heavy tasks due to shortness of breath and fatigue
in the past two weeks.” Symptom analysis/HPI: The patient is a 60-year-old Hispanic male
who presents with complaints of experiencing shortness of breath and fatigue for the past
two weeks. The patient reports that his cough has become productive with green sputum.
Later he developed a mild fever Pneumonia Soap Note Acute Conditions Paper