April 1, 2022

Nursing

Faculty Comments: Faculty Comments: Points Description
Subjective
5 Chief complaint stated in patient’s own words.
10 HPI, PMH, PSH, Family History, Social Habits,
10 Contains all systems relevant information to make assessment with normal and abnormal findings.
20 Objective present and contains all pertinent objective information available (drug allergies, physical findings, drug list, etc)
20 Assessment presents justification for Main or Primary diagnosis
15 Assessment rules out other potential disorders
5 Plan contains discussion of therapy options with pros and cons of each. Also
10 Plan stated as directives (start, stop, non-pharmacologic and pharmacologic treatment etc)
5 Plan include monitoring and follow up.

<table border="0" width="100%" cellpadding="0" cellspacing="0"> <tr> <td bgcolor="#000000" style="padding-left:2px; padding-right:10px; padding-top:2px; padding-bottom:2px">   Miami Regional University   (Acct #3111)</td> </tr> </table> <table border="0" width="100%" cellpadding="0" cellspacing="0" bgcolor="#C0C0C0"> <tr> <td width="50%">  Case ID #: 2844-20220315-004   (Status: Approved) </td> <td width="50%"> Date of Service: 3/15/2022 </td> </tr> </table> <table border="0" cellspacing="0" WIDTH="100%" bordercolor="#99CCFF"> <tr> <td WIDTH="100%" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px"> Student Information – Santiesteban Molina, Osmel</td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right"> Semester:</td> <td WIDTH="50%" bgcolor="#FFFFFF"> Spring </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right"> Course:</td> <td WIDTH="50%" bgcolor="#FFFFFF"> MSN6150C Advanced Practice Pediatrics </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right"> Preceptor: </td> <td WIDTH="50%" bgcolor="#FFFFFF"> REYES-CHOUZA, CARLOS </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18" valign="top"> Clinical Site:</td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"> IDEAL MEDICAL CENTER </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18" valign="top"> Setting Type:</td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"> Underserved area/population </td> </tr> <tr> <td WIDTH="100%" bgcolor="#000000" align="right" colspan="2" style="border-style: solid; border-width: 2px"> Patient Demographics</td> </tr> <tr> <td bgcolor="#FFFFFF"> Age:</td> <td bgcolor="#FFFFFF"> 8 years </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF"> Race:</td> <td WIDTH="50%" bgcolor="#FFFFFF"> White, Non Hispanic </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF"> Gender:</td> <td WIDTH="50%" bgcolor="#FFFFFF"> Male </td> </tr> <tr> <td bgcolor="#FFFFFF"> Insurance:</td> <td bgcolor="#FFFFFF"> Medicaid </td> </tr> <tr> <td bgcolor="#FFFFFF"> Referral:</td> <td bgcolor="#FFFFFF"> No referral </td> </tr> <tr> <td valign="top" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px"> Clinical Information</td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> Time with Patient:</td> <td bgcolor="#FFFFFF"> 15 minutes</td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> Consult with Preceptor:</td> <td bgcolor="#FFFFFF"> 5 minutes</td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> Type of Decision-Making:</td> <td bgcolor="#FFFFFF"> Straightforward </td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> Reason for Visit:</td> <td bgcolor="#FFFFFF"> Episodic </td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> Chief Complaint:</td> <td bgcolor="#FFFFFF"> Per mother:"My son looks pale and is always tired" </td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> Type of HP:</td> <td bgcolor="#FFFFFF"> Problem Focused </td> </tr> <tr> <td bgcolor="#FFFFFF" align="right" valign="top"> Social Problems Addressed:</td> <td bgcolor="#FFFFFF"> Income/Economic Sanitation/Hygiene Safety Interpersonal Relationships Emotional Growth & Development Nutrition/Exercise  </td> </tr> </table> <TABLE BORDER="0" CELLPADDING="0" CELLSPACING="0" WIDTH="100%" bordercolor="#99CCFF"> <tr> <td width="100%" bgcolor="#000000" align="center" colspan="2" style="border-style: solid; border-width: 2px"> Procedures/Skills (Observed/Assisted/Performed)</td> </tr> <tr> <td width="100%" bgcolor="#FFFFFF" align="left" colspan="2"> Physical Assessment – Physical Assessment (Perf) </td> </tr> </table> <table border="0" cellspacing="0" WIDTH="100%" bordercolor="#99CCFF"> <tr> <td width="100%" bgcolor="#000000" align="center" colspan="2" style="border-style: solid; border-width: 2px"> ICD-10 Diagnosis Codes</td> </tr> <tr> <td width="10%" bgcolor="#FFFFFF" align="right" valign="top"> #1 -  </td> <td width="90%" bgcolor="#FFFFFF" align="left"> D50.9 - IRON DEFICIENCY ANEMIA, UNSPECIFIED </td> </tr> <tr> <td WIDTH="100%" align="right" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px"> CPT Billing Codes</td> </tr> <tr> <td width="10%" bgcolor="#FFFFFF" align="right" valign="top"> #1 -  </td> <td width="90%" bgcolor="#FFFFFF" align="left"> 99212 - OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; STRTFWD MED DECISION; 10-19 MIN </td> </tr> </table> <table border="0" cellspacing="0" WIDTH="100%" cellpadding="1"> <tr> <td WIDTH="100%" align="right" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px" bordercolor="#99CCFF"> Birth & Delivery</td> </tr> </table> <table border="0" cellspacing="0" WIDTH="100%" cellpadding="1"> <tr> <td WIDTH="100%" align="right" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px" bordercolor="#99CCFF"> Medications</td> </tr> <tr> <td width="50%" bgcolor="#FFFFFF" align="right"> # OTC Drugs taken regularly:</td> <td width="50%" bgcolor="#FFFFFF" align="left" valign="top"> 2</td> </tr> <tr> <td width="50%" bgcolor="#FFFFFF" align="right"> # Prescriptions currently prescribed:</td> <td width="50%" bgcolor="#FFFFFF" align="left" valign="top"> 2</td> </tr> <tr> <td width="50%" bgcolor="#FFFFFF" align="right"> # New/Refilled Prescriptions This Visit:</td> <td width="50%" bgcolor="#FFFFFF" align="left" valign="top"> 1</td> </tr> <tr> <td width="50%" bgcolor="#FFFFFF" align="left" valign="top"> Types of New/Refilled Prescriptions This Visit: Hematology/Oncology – Miscellaneous hematology/oncology  </td> <td width="50%" bgcolor="#FFFFFF" align="left" valign="top"> Adherence Issues with Medications:  </td> </tr> </table> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="0" WIDTH="100%" bgcolor="#FFFFFF"> <tr> <td WIDTH="100%" align="right" bgcolor="#000000" colspan="2" bordercolor="#99CCFF" style="border-style: solid; border-width: 2px"> Other Questions About This Case</td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18"> Patient's Primary Language:</td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"> English </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18"> Smoking Assessment:</td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"> Never </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18"> Advanced Directive:</td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"> No </td> </tr> <tr><td bgcolor='#FFFFFF' valign = 'top' width='50%'>Packs per day:</td><td bgcolor='#FFFFFF'>0</td></tr> </table> <TABLE BORDER="0" CELLPADDING="0" CELLSPACING="0" WIDTH="100%" bgcolor="#FFFFFF"> <tr> <td width="100%" bgcolor="#000000" align="left" valign="top" colspan="2" bordercolor="#99CCFF" style="border-style: solid; border-width: 2px"> Clinical Notes</td> </tr> <tr> <td width="100%" bgcolor="#FFFFFF" align="left" valign="top" colspan="2"> </td> </tr> </table>

Grading Rubric

Student______________________________________

This 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) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b) Pertinent positives and negatives must be documented for each relevant system.

c) 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) Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.

5) Plan (___15pts.): Be sure to include any teaching, health 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 support 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.

Review 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 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 support 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. This 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 support the dx. Include the interpretation of all lab data given in the case study and explain how those results support 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 support ordering each medication. Be sure to include both prescription and OTC medications.

2. Additional diagnostic tests include EBP citations to support 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 support 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 #1 DX: Allergic Rhinitis

PATIENT INFORMATION

Name: Ms. JD

Age: 23-year-old

Gender at Birth: Female

Gender Identity: Female

Source: Patient

Allergies: NKDA

Current Medications:

· Cetirizine 10mg/d

· Mucinex-D

PMH:

Immunizations: Tetanus.

Preventive Care: No history.

Surgical History: No history of surgery.

Family History: Father- alive, 60 years old, healthy.

Mother-alive, 54 years old, HTN, hyperlipidemia.

Sister-alive, 20 years old, Asthma.

Social History: Denies alcohol, tobacco or illicit drugs use. College student, lives alone in campus hostels. Physically active and occasionally does exercise.

Sexual Orientation: Active

Nutrition History: Eats balance diet but avoids excessive junk food.

Subjective Data:

Chief Complaint: “stuffy nose” that has lasted for two weeks.

Symptom analysis/HPI:

Ms. JD is a 23-year-old patient who presents with complaints of a stuffy nose, rhinorrhea, congestion and sneezing. She reports a spontaneous start of the symptoms that have remained consistent. Indicates no particular aggravating symptoms but reports higher severity of the symptoms in the morning. She complains of a sore throat and itchy eyes. She reports an all-day clear runny nose. She indicates consistent outdoor handball practice routine. She reports using Cetirizine and Mucinex-D which do not help. She denies vision or taste changes. She denies fever or chills. Denies diagnosis with allergies.

Review of Systems (ROS)

CONSTITUTIONAL: Denies change in weight, fatigue, fever, night sweats or chills. NEUROLOGIC: Denies seizure, numbness or blackout.

HEENT: HEAD: Denies headache. Eyes: Reports itchy eyes. Denies vision change. Ear: Denies hearing loss, pain or discharge. Nose: Admits stuffiness, nasal congestion and clear discharge. Denies nose bleeds. THROAT: Reports a sore throat.

RESPIRATORY: Patient denies breathing difficulties, cough, wheezing, TB, pneumonia.

CARDIOVASCULAR: No palpitations or chest pain. No edema, PND or orthopnea.

GASTROINTESTINAL: Denies nausea, abdominal pains, vomiting and diarrhea. Denies ulcers hx.

GENITOURINARY: Denies change in urine color, urgency and frequency. Regular menses cycle. Denies ovulation pain. Denies hematuria and dysuria.

MUSCULOSKELETAL: Denies back and joint pains or stiffness.

SKIN: No skin rashes or lesions.

Objective Data:

VITAL SIGNS: Temperature: 36.7 °C, Pulse: 78, BP: 119/87 mmHg, RR 20, PO2-97% on room air, Ht- 1.60m, Wt 67kg, BMI 26.

GENERAL APPREARANCE: Healthy appearing. Alert and oriented x 3. No acute distress. Well-groomed and responds appropriately.

NEUROLOGIC: Alert, oriented, posture erect, clear speech. gait. to person, place, and time.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses mild tenderness. Eyes: Bilateral conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No edema, no lesions, no haemorhage. Clear discharge. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Nose: Mild erythema of nasal mucosa which is paly and boggy, congested nares with rhinorrhea. No nasal crease. Throat: Posterior pharynx with no tonsillar edema, erythema or exudate. Uvula midline. Moist mucous membranes.

Neck: supple. No cervical or post auricular lymphadenopathy. No thyroid swelling or masses. Non tender

CARDIOVASCULAR: S1and S2. RRR w/o sound. Capillary refill in 2 sec. Pulse >3.

RESPIRATORY: Regular respiration. Thorax symmetrical. No increased respiratory effort. Breath sounds vesicular on auscultation.

GASTROINTESTINAL: No hepatosplenomegaly. Bowel sounds present in all four quadrants. no bruits over renal and aorta arteries. Soft, non-distended, non-tender abdomen with no palpation.

MUSKULOSKELETAL: Full motion range in all extremities.

INTEGUMENTARY: intact, no lesions or rashes.

ASSESSMENT:

Main Diagnosis

Allergic Rhinitis (ICD-10 code J30.8)

Allergic rhinitis is an inflammatory infection of the nasal mucosa characterized by nasal congestion, sneezing and rhinorrhea (Greiner et al., 2011). It is an inflammation of the interior nasal lining due to inhalation of an allergen that results in a runny nose, stuffy nose, itchy eyes and sore throat (Seidman et al., 2015).

Differential diagnosis:

· Viral Rhino Sinusitis

Characterized by headaches, sore throat, nasal congestion, fever and sneezing (Reintjes & Peterson, 2016). Patient denied headache or fever.

· Acute Conjunctivitis

Associated with red eye and mucopurulent discharge and at times lack of itching (Azari & Barney, 2013). Patient reported itchy eyes but with a clear discharge.

PLAN:

Labs and Diagnostic Test to be ordered:

· Skin

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Nursing

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