Urinary tract infection

Soap Note # ____ Main Diagnosis ______________

PATIENT INFORMATION

Name:

Age:

Gender at Birth:

Gender Identity:

Source:

Allergies:

Current Medications:

1.

PMH:

Immunizations:

Preventive Care:

Surgical History:

Family History:

Social History:

Sexual Orientation:

Nutrition History:

Subjective Data:

Chief Complaint:

Symptom analysis/HPI:

The patient is …

Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL:

SKIN:

Objective Data:

VITAL SIGNS:

GENERAL APPREARANCE:

NEUROLOGIC:

HEENT:

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:

ASSESSMENT:

(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)

Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)

Main Diagnosis

(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 7th Edition.

Differential diagnosis (minimum 4)

–

–

PLAN:

Labs and Diagnostic Test to be ordered (if applicable)

1. –

1. –

Pharmacological treatment:

–

Non-Pharmacologic treatment:

Education (provide the most relevant ones tailored to your patient)

Follow-ups/Referrals

References (in APA Style)

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 (5/5pts): 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 (30/30pts.): 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.(10/10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10/10pts).

c) Any PMH, family hx, social hx, allergies, and medications related to the complaint/problem (10/10pts). If more than one chief complaint, each should be written u in this manner.

3)Objective Data(25/25pt.): 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.(10/10pts).

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. (5/5pts).

4)Assessment (10/10pts.): Diagnoses should be clearly listed and worded appropriately. REMEMBER NEED TO USE A ICD 10 CODE FOR ENCOUNTER

5)Plan (15/15pts.): 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 (10/10pts.): 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(5/5pts.): Is it literate, organized and complete? Remember to use APA when doing any type of writing or papers at the Nursing Graduate level.

Comments:

Total Score: