Write A Focused Soap Note? A mother brings her 14-year-old daughter

PRAC 6541: Primary Care of Adolescents and Children

Focused SOAP Checklist

SUBJECTIVE:

· Chief Complaint: Did I state briefly in the patient’s own words

· History of present illness: Did I write a paragraph in the order of the 7 attributes & did I put the 7 attributes in a concise list in the chart (OLD CART-if you don’t know it, please look it up)

· Medications: did I list each medication and reason.

· Allergies: Did I include specific reactions to medications, foods, and insects, environmental?

· Past Medical History (PMH): Did I list all the patient Illnesses, hospitalizations? Did I Include childhood illnesses

· Past Surgical History (PSH): Did I list the dates, indications and types of operations?

· OB/GYN History: (if applicable) Obstetric history, menstrual history, methods of contraception and sexual function.

· Personal/Social History: Tobacco use, Alcohol use, Drug use, risky sexual behavior. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits. Pediatrics: school status, parental smoking hx, birth history, school/daycare etc

· Immunizations: Did I include Last Tdap, Flu, pneumonia, etc. Pediatrics- (per pediatric schedule for age) HPV if applicable

· Family History: Did I list for Parents, Grandparents, siblings, children?

· Review of Systems (SUBJECTIVE DATA): Did I include the systems related to my Chief Complaint and chronic conditions? Did I type detailed description? I did NOT use WNL. I was specific in my descriptions (see health assessment textbook). Did I remember this is what the patient says and not what I observed? Did I include the cardiovascular and respiratory system regardless of chief complaint?

Physical Exam: (OBJECTIVE DATA) This is what YOU see/touch/hear/smell

· Did I list the vital signs as the first thing in the objective section? Did I include the BMI for adults? Did I include the percentile for the ht, wt, bp etc for pediatrics?

· Did I examine the systems that are pertinent to the CC, HPI, and History. Did I describe what I observed? Did I never use WNL or normal? Did I describe what I observed during the physical exam?

· Did I include the systems in a list format?

· Did I include cardiovascular and respiratory systems regardless of cc?

· Did I delete the systems I did not review?

ASSESSMENT:

· Did I put my priority diagnosis in bold for EACH CC?

· Did I include at least 3 differentials(DD) after the priority diagnosis for EACH of my CC?

· Did I explain what each DD is, use references to explain and tell how you ruled in or ruled out each DD? (AND does your ROS and PE reflect this?)

· Did I include a reference citation for each diagnosis under the assessment area?

· Are my assessments concise and in a chart format?

· Did I put my differential diagnosis in order by priority?

· Did I provide a detailed rationale for each diagnosis?

Holistic care:

· Did I cover existing diagnoses and whether any changes need to be made?

· Did I include needed preventative care based on my patient’s age and risk factors?

PLAN:

· Did I include a treatment plan?

· Did I address if labs, x-rays, etc. were needed?

· Did I include a pharmacological plan and citation for EBP?

· Did I include non-pharmacological strategies?

· Did I discuss alternative therapies if applicable?

· Did I state when the patient needs a follow-up?

· Did I indication if any referrals or consultations were necessary or not necessary?

· Did I write a rationale based on evidence?

· Health Promotion: Did I address this area? Did I state what the patient/ family need to do to promote their health based on the USPTF for adults or Bright Futures for children? Did I document my citations?

· Disease Prevention: Did I do these based on recommendations from USPTF for adult’s or Bright Futures for children based on the patient’s age? Did I state what needs to be done to detect disease early…fasting lipid profile, mammography, colonoscopy, immunizations, etc? Did I cite the source?

REFLECTION:

· Did I state what I learned from this experience?

· Did I state what I would you do differently or if I would do everything the same and the rationale?

· Did I state if I either agreed or disagreed with my preceptor based on evidence (and cite references for EBP?

· Did I state what I would do if the person was insured versus if the person was not insured? Indicate how this would change your plan.

· Did I state the community resources in my area?

APA

· Do I have a minimum of 3 scholarly journal articles? (NONE OF WHICH ARE PATIENT EDUCATION SITES THAT I GOOGLED)

· Did I use at least 3-4 course resources?

· Do I have the paper in a neat format?

· Did I list my references in APA format?

Developed by Joyce Turner, NP. Revision 2/22/17 by Nancy Hadley, DNP, APRN, FNP-BC

© 2020 Walden University 1

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