Academic clinical SOAP notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating evidence-based plans of care.
This assignment uses a template. Locate the “Academic SOAP Note Template” on the Student Success Center page under the AGACNP tab.
Develop a hospital follow-up progress SOAP note based on a clinical patient from your practicum setting. In your assessment, provide the following:
- A one-sentence description of the primary working diagnosis, pending differential diagnoses, and the context or service in which the patient is being seen.
- A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures. Include how many days the patient has been hospitalized, if applicable.
- List of at least five systems affected by the working diagnosis. Provide two positive or negative effects that the working diagnosis has on each system.
- List of at least five systems examined within the past 24 hours. Provide at least two pertinent positive or negative findings relevant to each system examined and include a full set of vital signs.
- List of all admission diagnostics conducted for this visit or conducted within the past 24 hours.
- List of all pertinent acute and chronic diagnoses in order of priority using ICD-10. Identify any differential diagnoses being eliminated.
- Treatment plan that corresponds with the diagnosis. Provide information on admission type, types of diagnostics, any prescribed medications and dosages, and any relevant consults or follow-up procedures needed.
- Discussion of any relevant ethical, legal, or geriatric-specific considerations.
Incorporate at least three peer-reviewed articles in the assessment or plan.
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite Technical Support Articles is located in Class Resources if you need assistance.
Running head: BENCHMARK: ACADEMIC CLINICAL SOAP NOTE 1
Benchmark Academic Clinical Soap Note
Grand Canyon University
ANP 652
February 05, 2020
Admission Date: 12-03-2019
Chief Complaint:
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2
BENCHMARK: ACADEMIC CLINICAL SOAP NOTE
Patient c/o worsening SOB since this morning.
Background:
This is a pleasant 33-year-old obesity Hispanic male who presents to emergency room
and does not go and see any doctor, comes in with some shortness of breath and cough. Pa-
tient notes that he has been having shortness of breath with productive cough for a few days.
Patient states his wife also notes he has been wheezy however denies any history of COPD,
asthma or smoking. Patient does note he works in construction and dry wall however does
use respirator. Nothing has made symptoms better. Symptoms were worse after walking and
shower at home. No eliciting factors have been noted. Symptoms are moderate to severe. Pa-
tient does have some productive sputum and intermittent wheezing. Denies any history of
COPD, asthma, similar illness. Denies any smoking. Denies any hemoptysis. Patient does
note he works in construction and dry wall however does use respirator.
Hospital Medications:
❖ acetaminophen, 650 mg= 2 TAB, PO, Q4H (Every 4 hours), PRN
❖ Albuterol NEB, 2.5 mg= 3 mL, NEB, TID (3 times a day)
❖ Albuterol NEB, 2.5 mg= 3 mL, NEB, Q2H (Every 2 hours), PRN
❖ cefTRIAXone 2 g IV Push, Q24 (Every 24 hours)
❖ montelukast, 10 mg= 1 TAB, PO, QHS (At bedtime)
❖ nitroglycerin, 0.4 mg= 1 TAB, Sublingual, 5MX3 (Every 5 minutes x 3 doses), PRN
❖ ondansetron, 4 mg= 2 mL, IV Push, Q4H (Every 4 hours), PRN
❖ Saline Flush, 10 mL, IV Push, Q12H (Every 12 hours)
❖ Zithromax, 500 mg= 2 TAB, PO, Q24H (Every 24 hours)
Review of Systems:
Constitutional: No fever, no chills, no sweats, no weakness.
Eye: No recent visual problem, icterus, discharge, blurring, double vision.
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Benchmark – Academic Clinical SOAP Note – Rubric
Collapse All Benchmark – Academic Clinical SOAP Note – RubricCollapse All
Primary or Working Diagnosis (B)
6 points
Criteria Description
Primary or Working Diagnosis (C6.2)
5. Target
6 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen is provided and includes supporting details.
4. Acceptable
5.4 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen is provided accurately.
3. Approaching
4.8 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen, is provided.
2. Insufficient
3 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen, is incomplete or incorrect.
1. Unsatisfactory
0 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen, is not provided.
Brief Clinical Course (B)
6 points
Criteria Description
Brief Clinical Course (C7.4)
5. Target
6 points
A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is complete with supporting documentation.
4. Acceptable
5.4 points
A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is complete.
3. Approaching
4.8 points
A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is supported with minor details missing.
2. Insufficient
3 points
A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is only partially supported.
1. Unsatisfactory
0 points
A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is not provided.
Running Head: SOAP NOTE 1 1
PROGRESS NOTE 5 4
SOAP Note I
Students Name
Grand Canyon University
ANP XXX
Date
SOAP Note Example
Brief HPI: This is a 79 year old female, B.G., whom was admitted two days ago from the ER with complaints of lower extremity weakness and difficulty breathing. Admitting diagnoses were LE weakness and non-small carcinoma. B.G. has a medical history significant for COPD in which she requires home oxygen as needed for shortness of breath. She is very familiar to the pulmonary group and was seen at a sister campus last month for healthcare associated pneumonia.
If the patient has been hospitalized for a period of time, include a brief summary of the hospital course.
Subjective
Patient reports, “My breathing feels better today but I am still very weak” (This is your chief complaint. It is the answer to the question, “How are you doing today?” If patient unable to state, ask the nurse or the family member “How is the patient doing?) She reports constipation, last BM was three days ago, but denies any pain and started taking Miralax yesterday. Her leg weakness is slightly improved, and she states she has been able to get back and forth to the restroom with minimal assistance.
Inpatient Medications (Include dosage, route, and frequency)
Review of Systems (You must review at least 5 systems and include at least two pertinent positives or negatives per system)
Gen: Denies fever, chills
PULM: C/o shortness of breath. Increased with exertion. Improved over yesterday.
CV: Denies CP, palpitations
GU: Denies difficulty with urination. Clear yellow urine per patient.
GI: No change in bowel habits. No BM X3 days.
Ext: C/o lower extremity weakness. Denies pain.
Objective
Physical Exam
VS: Tmax 37.4- HR 60- RR 24- BP 147/70- 98% 3L via NC (Include if the are on RA, O2, Vent)
Constitutional: In respiratory distress, nontoxic.
Neuro: AAOx4, speech clear, PERRL, EOMI, no focal deficits.
HEENT: Normocepahlic, MM dry and pink, neck supple, trachea midline.
Cardiac: S1 S2, RRR at this time.
Resp: Labored, tachypneic, clear, equal rise and fall.
GI: Semi-firm, round, nontender, BS are present.
Derm: Skin warm, dry, and pale. No lesions.
Ext: Pulses easily palpable x4, no edema present, strength 4/5 all extremities.
Diagnostic Tests (Include any diagnostic tests from the last 24-48 hours. Include your interpretation of the test. Identify abnormal findings by
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