Soap note 7/ chronic gout

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

please explain 3 differential dignosis

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: ___________________

(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 pa

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  Miami Regional University   (Acct #3111)</td>
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<td width=”50%”>  Case ID #: 2844-20210928-001
  (Status: Approved)
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Date of Service:
9/28/2021 </td>
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Student Information – Santiesteban Molina, Osmel</td>
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Semester:</td>
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Fall

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Course:</td>
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MSN5700C Advanced Practice in Primary Care I

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Preceptor: </td>
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TREJO, RODOLFO

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Clinical Site:</td>
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Neighborhood Family Doctor.Atlantis

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Setting Type<font size=”2

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Soap note 7/ chronic gout

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