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Evaluate and critique a SOAP note for completeness and thoroughness

Evaluate and critique a SOAP note for completeness and thoroughness

Evaluate and critique a SOAP note for completeness and thoroughness.

  1. Review this sample SOAP note . Explain what needs to be done to improve this note and why. Be sure and identify the following:
    • Eight (8) or more data points in the subjective history that need improvement
    • Seven (7) or more data points in the objective history that need improvement
    • For each diagnosis or differential diagnosis identified, is the pertinent positive and negative data thorough and accurate?
  2. Your response should contain a discussion of National Guidelines and ARHQ Health Promotion recommendations (according to the United States Preventative Task Force [USPTF]) appropriate to the case.

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Sample Soap Note Critique

  1. Introduction

 

  1. Identifying data: D. R.

 

  1. Source and reliability of history: Patient is a reliable historian

 

  1. Demographics:

 

  1. Gender: Male
  2. Age: 16 year/old
  3. Marital status: Unmarried
  4. Ethnicity: Hispanic  
  5. Social/Occupation: Lives in Westlyn with mother, father, and brother. Attends high school. Good grades, attendance and relationships with teachers
  6. LMP=1st day of last menstrual period: NA
  7. Current regular & prn meds prescribed and OTC: Phenergan-Codeine Syrup for cough; Tylenol and Ibuprofen prn for pain fever.

 

  1. Chief Complaint (CC)- Specific reason for clinic visit: Nausea, vomiting, diarrhea

 

  1. SOAP Components

 

  1. Subjective

 

  1. HPI (OLDCART)

Onset: 0300 hrs today

Location: Abdomen, head, chest, generalized body aches

Duration: Intermittent

Contributing Factors – Previous flu

Relieving factors – Rest

Treatments – Acetaminophen and ibuprofen, Phenergan/codeine syrup

 

  1. PH:

Diagnosed with Influenza Type A

No other significant medical history;

No surgeries;

No significant traumas

 

  1. Preventive health: Receives regular medical exams, vision and dental screening. Denies regular exercise.

 

  1. Focused ROS:

 

General:  Fever, chills, and weakness; denies rash

 

HEENT: Head: Positive for headache; Eyes: positive for eye pressure; denies eye pain, photophobia, changes in vision; Ears: positive for congestion; denies ear pain, hearing loss, drainage; Nose: positive for yellow nasal discharge and congestion; Sinuses: positive for facial pain and tenderness; Mouth: denies difficulty chewing, denies oral or dental pain; Throat: positive for throat pain, denies difficulty swallowing or hoarseness

 

Respiratory System: positive for cough, chest tightness, shortness of breath on exertion; denies pain during breathing or difficulty breathing during rest

 

Cardiovascular System: Positive for chest pain during coughing, denies shortness of breath without exertion, dizzy spells, referred neck/jaw or arm discomfort or numbness, denies peripheral edema, palpitations or irregular heart rate

 

Abdominal: denies vomiting

 

GU: denies difficulty urinating, pain during urination, changes in urination

 

Neurological: admits to occasional headaches; denies unilateral headaches

 

 

  1. Family History

Maternal Grandfather – Alive and well

Maternal Grandmother – Diabetes

Mother – Hypothyroidism

Father – HTN

Brother – Alive and well

Evaluate and critique a SOAP note for completeness and thoroughness

  1. Objective

 

Physical Exam

 

General: Height: 6’, Weight: 230 lbs; BSA: 2.261. VS: B/P 118/78, Temp: 99.3 F., Respirations: 18 b/m, SPO2: 97% on room air

Appears acutely ill; no apparent distress, cooperative, alert and oriented x 3, obese, dressed appropriately for weather

 

Skin: Warm, dry, good turgor, soft, no rashes, lesions, masses and without hyper/hypo pigmentation or discoloration, no nodules or visible masses, no lacerations, abrasions, or ulcerations, no nail changes, there is normal hair distribution without abnormal hair loss

 

HEENT: Head: The head is normocephalic; Eyes: EOMs present bilaterally, pink and moist conjunctivae, no exudates, PERRLA, white sclera, normal gross visual acuity, no nystagmus, ptosis, no papilledema, hemorrhages, or exudates; Ears: ear canals free from discharge, foreign bodies, masses, impactions, tympanic membranes erythematous without bulging, retractions, or injections bilaterally; Nose: nares patent, no septal deviation, nasal turbinates are erythematous and edematous; yellow discharge visible; Mouth: Oral mucosa is intact and moist, halitosis present, no lesions, masses, or exudates, the pharynx is erythematous, the tonsils are present and slightly edematous bilaterally and without exudates; gag reflex is intact; the tongue protrudes midline without deviation

Neck: Tender left and right cervical lymph nodes, neck is supple with normal ROM, trachea is midline, no stridor noted; no jugular venous distension, no audible carotid bruits, carotid pulses strong bilaterally

 

Respiratory System: Lungs are clear to auscultation in all fields A & P with a normal rate and rhythm, the lung fields are resonant bilaterally, normal vesicular breath sounds present, no rales, rhonchi, wheezes, or rubs noted; the bony thorax is intact without deformities, symmetrical chest expansion;

 

Cardiovascular System: Heart auscultation is without murmur, gallop, clicks, or rubs with normal rate and rhythm.  Normal S1 and S2, no S3 or S4 noted, heart rate at 78 beats per minute with regular rhythm, peripheral pulses are present with regular rhythm

 

Abdominal: Abdomen is round, smooth, and without rigidity or distension. Bowel sounds active in all four quadrants, no splenomegaly, and no hepatomegaly.  Striae present to lower abdomen

 

Musculoskeletal: normal ROM to upper and lower extremities, no rigidity, good muscle strength and coordination

 

Diagnostics: Rapid Strep test negative, Rapid Flu test negative, Mono Spot negative

 

  1. Assessment

 

  1.   Differential diagnoses:  based on fever, congestion, maxillary sinus                                         tenderness, generalized myalgia, cough, headache, eye pressure, and fatigue

 

  1. Acute Maxillary Sinusitis with Viral Syndrome – probable based on PE, recent history of Influenza, maxillary sinus pain to palpation/percussion, fever, nasal congestion, cough (worse at night), fatigue, headache, eye pressure, halitosis, and sore throat.
  2. Streptococcal pharyngitis – possible based on PE and History – Rapid Strep test negative
  3. Infectious Mononucleosis – possible based on history and PE – fatigue, weakness, sore throat, fever, swollen and tender cervical nodes, erythematous and edematous tonsils, headache, loss of appetite – Mono Spot negative
  4. Adenovirus infection – possible based on History and PE – sinusitis possibly a secondary infection due to adenovirus infection – positive for fever, rhinorrhea, cough, sore throat, fatigue, diarrhea, abdominal cramps
  5. Meningitis – possible but not likely based on History and PE – positive for nausea, fever, fatigue, chills, myalgia, and diarrhea. Negative for tachypnea, rash, vomiting, photophobia, nuchal rigidity/neck stiffness, or altered mental status

 

  1. Diagnoses: Acute Maxillary Sinusitis with Viral Syndrome

 

  1. Plan
  2. Patient education – take fluids, take medications as directed; wash hands and cover cough, rest, obtain meningococcal vaccination once recovered. Return to school when no fever after 24 hours without use of antipyretics

  3. Treatment     – Decadron; Vibramycin; Tylenol alternating with ibuprofen prn pain/fever. Continue phenergan/codeine for cough.

 

  1. Further diagnostic evaluation – throat culture