SOAP Note Clinical Visit for Chronic disease
Soap notes on any chronic disease follow the grading scheme (Very important for good score) HPI CC in the patient's own words. Include age, ethnicity and gender in the opening sentence. A.)If a new problem, include all elements of OLDCARTS as appropriate. B.)Include pertinent positives and negatives from the ROS associated with the CC. Do not repeat documentation later in the ROS section of the note when included in the HPI. C.)If the patient has a chronic problem include an update of what the patient has or has not done since the last visit. Refer to the last plan of care and include medication/ tolerance/ adherence, labs, treatment, referrals, diet, exercise, and lifestyle changes. Only one of four SOAP notes will include an update on a chronic illness without differential diagnoses (see addendum). D.)Include pertinent PMH: illnesses, injuries, hospitalizations, surgical, psych, OB, sexual history and family history if appropriate to the CC/ chronic illness.(35pts) Allergy/Medications Complete listing of allergies and all medications including OTCs: common, herbal, naturopathic remedies, Chinese. Include dose, route, schedule, and adherence.(2 pts) Social History-Personal/social history appropriate to CC. Should always include tobacco (personal use and/or secondhand), ETOH, drugs. Other elements that may be appropriate include environmental issues; violence; HEAAADS; coping; risks/safety; marital status; family; support; occupation; finances(3pts) ROS-Inquires about the system(s) related or important to the problem(s) identified in HPI and the differential diagnoses. Document pertinent positives and negatives.(5pts) Objective Includes VS and BMI. Includes all essential elements appropriate to the patient's CC, HPI, and differential diagnoses. Document systems in thorough detail for an advanced practice assessment. The objective exam meets the criteria for detailed or comprehensive exam. See CMS criteria in course documents. Include any in- office lab results or lab results pertinent to the differential diagnoses.(20pts) Assessment/Diagnosis Accurately identifies significant diagnosis (es) and concerns from subjective and objective data collected. Address acute and chronic health problems. No diagnosis (es) listed without adequate support in the hx and exam. Consider abnormal BMI, social problems, risks, and lifestyle modifications needed.(15pts) Appropriate diagnostic tests based on efficacy, safety, cost, according to current guidelines and patient acceptability. Student will receive full points if no further testing according to current guidelines is warranted or if a full explanation why the testing suggested by the guidelines was not ordered (not available, high cost, patient preference, for example).(10pts) Plan: Intervention Appropriate therapeutic interventions (pharm & non-pharm) based on current evidence. Include medication, name, dose, number given, route, frequency, length of time and number of refills prescribed for all medications. Include orders for referral to other therapeutic modalities.(25pts) Plan: Education Health education including health promotion relevant to diagnoses.(5pts) Follow-up Follow-up interval, with whom the patient is to follow-up, what the patient should do if no improvement along with a time frame. Include: "return sooner if worse" in the plan.(5pts) Diagnoses or Chronic Illness Update A.)Differential Diagnoses: Write three differential diagnoses for the primary problem in order of priority based upon the preponderance of evidence from the DD table (attached). B.) Pathophysiology: Write a short paragraph describing the pathophysiology associated with each DD. Include citations and references in APA format. C.) Rationale: Provide a statement of rationale for accepting or rejecting each dx and why a dx is most likely synthesizing the information in your DD table. If a dx cannot be ruled out due to evolving symptoms or pending tests, state so and why. D.)Next Steps: Based upon the pathophysiology of the diagnosis and expected findings from the literature, indicate if additional history, exam, diagnostics/ labs/or time are yet needed to make a firm diagnosis. Include citations and references in APA format. D.) Discussion: Provide a discussion of the questions that you had in this case and how you resolved them (met with preceptor/ literature review/ guidelines, etc). Discuss any other DD that may still be considered for this patient and why. List any red flags in the history and exam or those associated with potential for high risk problems including the diagnosis, co- morbidities, medications, etc. Cite the literature using APA format to support your rationale.(35 pts) Guideline selection and comparison Clear and concise summary comparing and contrasting the plan of care with a current and relevant clinical guideline (www.guideline.gov). Includes a point- by- point comparison of diagnostic testing, intervention (pharmacologic/non-pharmacologic), education and follow up. If areas such as education and follow up are not included in the guideline, state so. Epocrates, Merck, or commercial web sites are not acceptable sources for guidelines. See the Guideline Selection Criteria in the course documents.(25pts) Reflection Thorough but concise point- by- point discussion of what went well and what you would have added to the clinical SOAP note (subjective/objective data collection, diagnosis or treatment plan) based upon current guidelines. Cite current guidelines/ literature and provide references in APA format. Note: The Reflection is not a rewrite of the clinical SOAP note and is limited to only those items of the SOAP that you would change. Additional points may be added to missing elements of the electronic or hand written SOAP note (at the faculty discretion) if identified in this section and presented with adequate reflection.(15pts) Inter professional -Discusses actual or potential Inter- Professional collaboration on the plan of care. Discusses whom you would collaborate with (specialty) and how collaboration with other healthcare team members could potentially improve outcomes for the patient.(5 pts) Clarity/References/APA Cites at least two peer reviewed sources or national guidelines (Epocrates, Merck, or commercial websites are not acceptable). Textbooks may be used sparingly for background information but are not considered peer- reviewed guideline. Guidelines should be recent (within the last five years) unless the guideline remains the standard. Subjective and objective information is appropriately organized. Demonstrates use of good grammar, spelling and appropriate terminology. Uses APA format for citations. Cites references in text and provides bibliography in APA 7th edition format with no more than 1-2 minor errors.(10pts)
Chronic disease SOAP Note Example
Name
Affiliation
Course Code
Supervisor
Date
SUBJECTIVE
NAME: M. B AGE: 65 GENDER: FEMALE RACE: CAUCASIAN
CHIEF COMPLAINT: “I am here to undertake my wellness exam”
HPI: The patient is a 65 year old who is coming back for a clinical visit and claims to be in good condition. She has come for a clinical wellness exam and is completely unable to recall the most recent test that she took. She has stopped taking her asthma medication but says she has been getting vaccination against influenza. Due to allergy related to one of the prescribed medication, she says that she stop taking medication on a daily basis as she reported nose bleeding. Two days ago the patient also reported worsening of her shortness of breath with increasing needs for oxygen. Her past X rays indicated that there is persistent pneumonia. The CT scan also revealed that there is fluid around the heart and lungs, prompting her to be admitted for continue evaluation and management.
PMH: She has been admitted before for pneumonia at age 4 and was admitted for asthma at age 7. She is unable to lay flat, and cannot complete his activities of daily living due to shortness of breath.
Allergies/ Medication: Allergic to dust and currently takes Acetaminophen (TYLENOL) 325mg tablet, Albuterol Sulfate HFA (VENTOLIN HFA) 108(90) and Inhaler for Asthma
Social history: patient is a widow, lives with her elder daughter. She is not employed. She does not drink nor smoke. Her husband died of diabetes complications. Her daughter is living with asthma, she has a son who is also living with diabetes.
Review of Systems
Weight: No recent changes
Head: Denies headaches, sinus pain, or pressure
Eyes: Changes in visual acuity
Ears: Negative for any pain or tenderness
Nose: Negative for nasal drainage or congestion
Throat/Neck: Negative for sore throat, pain, or neck stiffness
Cardiac: Negative for palpitations, edema, chest pain, or dizziness
Respiratory: reports shortness of breath with mild exertion, denies sob at rest. Denies wheezing, coughing, or congestion.
Neuro/Psych: Mood appropriate.
Allergy/Immune: positive for dust and congested rooms
OBJECTIVE
Physical Examination:
Vital Signs: BP 106/68 Temp. 98.60 F Pulse: 95 Resp 33 SpO2 920
Labs: Personally reviewed and notable for; Lactate 1.33, Procalcitonin 0.20, BNP 140---- 361, BUN 28.
Imaging ECG Procedures personally reviewed and notable for:
CXR1 – No significant change from prior study.
CT Angio Chest W IV - No CT evidence of pulmonary embolism.
Physical Exam
General: patient is alert and well groomed. Overal vitals are stable.
Cardiovascular: Regular rate and rhythm, normal S1 and S2 sounds present. Negative for any murmurs, gallops, or rubs. Capillary refill is less than two seconds and pulses are +2 bilaterally. Trace +1 edema in BLE.
Lungs/Thorax: Decreased tactile fremitus. Hypo-resonance noted
to RLL. Fine crackles BLL. No wheezes, or rales present. Oxygen saturation on room air was 92%.
ASSESSMENT/DIAGNOSIS
Differential Diagnoses
The differential diagnosis included:
- Pericardial effusion – It was a differential diagnosis as the patient previous assessment indicated fluid around the heart, but other symptoms did not match to qualify as main diagnosis (Brucato & Maggiolini, 2018).
- Acute Anemia – was dismissed since there were no signs of bleeding.
- Asthma – The condition is characterized by shortness or breath, however other symptoms indicate that this was the treated when the patient was 7 years old and did not match the current symptoms (Karasu & Akin, 2023).
Main Diagnosis
- Acute on chronic hypoxic respiratory failure, unclear etiology Pleural effusion, bilateral Persistent asthma
This was the main diagnosis since the pathophysiology of the condition also comes with the release of cytokines which activates the alveolar macrophages that recruits neutrophils to the lungs releasing leukotrienes, oxidants, platelet, and proteases activation factor (Almazan et al., 2023). The substances are responsible for damaging capillary endothelium and alveolar epithelium leading to disruption of the barriers between the capillaries and airspace. It is the main diagnosis since the patient had been recently admitted for the same and she was managing through antibiotics.
PLAN
Pharmacological Intervention
- Continue PTA inhalers - Symbicort, albuterol.
- Furosemide 20 mg/ V first dose in ED, reassess renal function BP and labs for daily dose as a way of avoiding excessive volume depletion until there is cardio eval/plan.
- Do not continue IV antibiotics at this time.
Non- pharmacological intervention, education
Educate patient on critical components of asthma and chronic hypoxic respiratory failure. Including change of lifestyle and use of inhalers.
Follow-up: After a week
Reflection: The exercise was important in understanding techniques required to make a differential diagnosis for chronic conditions that almost look the same in terms of symptoms.
Inter professional: Generally, it is important for unprepared patients should exercise caution while dealing with this ailment
References
Almazan, E., Khan, M., & Maskey, A. (2023). Post-surgical bilateral Chylothorax resulting in acute hypoxic respiratory failure. B43. Uncommon Types And Causes Of Pleural Effusion: Case Reports In Pleural Disease. https://doi.org/10.1164/ajrccm-conference.2023.207.1_meetingabstracts.a3369
Brucato, A., & Maggiolini, S. (2018). Pericardial effusion. ESC CardioMed, 1572-1575. https://doi.org/10.1093/med/9780198784906.003.0377
Karasu, B. B., & Akin, B. (2023). Can asthma cause pericardial effusion? Insights into an intriguing association. Texas Heart Institute Journal, 50(2). https://doi.org/10.14503/thij-22-7867
