FNP 594: Common Illnesses Across the Lifespan
SOAP Note -Patient #
University
FNP 594: Common Illnesses Across the Lifespan
Professor
October 16, 2024
SOAP Note Patient #
ID:
- Client’s Initials: Age: DOB: 00/00/0000
- Race/ Ethnicity: Gender: ______
- Arrived at the clinic: With . The patient is a reliable historian.
Subjective
CC: " Patient’s own words, a few words, a sentence or less. Example: “cough and fever”
HPI:
In paragraph format, including at the minimum OLDCARTS. Please start with demographics: AA, a 29 y.o. Asian female presents to the clinic alone with complaint of _____________.
Onset, Location, Duration, Characteristics/context, Aggravating factors or Associated symptoms, Relieving Factors, Treatment, and Timing, Severity. Include any pertinent positives or negatives.
Past Medical/Psychiatric history: Hypertension, Hyperlipidemia, Type 2 Diabetes Mellitus, Benign prostatic hyperplasia (BPH), Osteoarthritis, Ischemic CVA 05/2019 with no lasting motor deficits, osteoarthritis of bilateral knees.
Surgeries and hospitalizations: 07/2021 after left hip replacement; 05/2019 after CVA; 2016 Hospitalization for pneumonia; 2022 cataract surgery on both eyes.
Preventive Care: Last eye exam:
Last dental visit:
Last colonoscopy:
He received all childhood vaccines.
Last flu shot:
Pneumonia shot:
Covid Vaccine: Last booster
Shingles Vaccine:
Tetanus booster:
Allergies: drug, food, latex, or environmental allergies
Current medications: include names, doses, frequency, and routes, and reason in parenthesis if off-label or secondary use
Social History:
Chemical history: Former smoker, quit 15 years ago. Smoked one pack/day for 30 years. DN admits that he does not use alcohol or illegal drugs. Caffeine intake is one cup of coffee a day.
Diet: He eats a fairly balanced diet nutritionally, but he admits to consuming processed food and, at times, skipping meals. He is able to walk small distances in the house but has decreased overall physical activity significantly in the past six months since the loss of balance.
Sexual History:
Occupation:
Housing:
Sleep:
Stress:
Safety: seatbelt and does not consume alcohol or use his phone while driving. guns in his home,
Spirituality:
ADLs:
Advanced directives:
Family History:
Mother:
Father:
Siblings:
Daughter:
Review of Systems
Professional SOAP Note Writing Service
General: (write out by system): Comprehensive (>10) ROS systems for wellness exams or complex cases only. Do not include all 14 systems for every SOAP unless needed - review and document the pertinent systems. Do not include diagnoses - those belong in PMH. The below categories are per CMS guidelines.
Eyes:
ENT:
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Endocrine:
Integumentary:
Hematologic:
Objective
H.R.:72 BP: 130/78 Temp: 98.4 F RR:16/min SpO2: 97% on RA.
Pain: 0/10 Height: 5’10 Weight: 170 lbs. BMI: 24.4 (be sure to include percentiles for peds)
Physical Exam
General Survey:
Eyes:
Ears/Nose/Mouth/Throat:
Neck:
Cardiovascular:
Pulmonary:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Integumentary & Breast:
Endocrine:
Hematologic/Lymphatic:
Allergic/Immunologic:
Neurological:
Psychiatric: (***notice not all systems are in the PE when doing a focused exam on a problem)
Assessment
(you will often have more than one diagnosis/problem, but do the differential on the main problem)
Differential Diagnosis
Differentials (with ICD 10 code and a brief rationale for each):
1.
2.
3.
Diagnosis (may have more than one, include ICD-10 if rubric or as your instructor specifies
Plan
Diagnostics
Treatment
Patient Education
Follow-up
References
