NRNP 6552: Advanced Nurse Practice in Reproductive Health Care
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint): This is a brief statement identifying why the patient is here in the
patients own words, for instance, headache, not bad headache for 3 days.
HPI: This is the symptom analysis section of your note. Thorough documentation in this
section is essential for patient care, coding, and billing analysis. Paint a picture of what
is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to
start every HPI with age, race, and gender (e.g., 34-year-old African American female).
You must include the seven attributes of each principal symptom in paragraph form, not
a list. If the CC was headache, the LOCATES for the HPI might look like the following
example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable
but not completely better
Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for
use. Also include over-the-counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a
description of what the allergy is (e.g., angioedema, anaphylaxis). This will help
determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major
illnesses, and surgeries. Depending on the CC, more info is sometimes needed.
© 2022 Walden University, LLC
NRNP 6552: Advanced Nurse Practice in Reproductive Health Care
Soc & Substance Hx: Include occupation and major hobbies, family status, vaping,
tobacco and alcohol use (previous and current use, how many times a day, how many
years), and any other pertinent data. Always add some health promotion questions
here, such as whether they use seat belts all the time or whether they have working
smoke detectors in the house, the condition of the living environment, text/cell phone
use while driving, and support systems available.
Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic
illnesses. The reason for death of any deceased first-degree relatives should be
included. Include parents, grandparents, siblings, and children. Include grandchildren if
pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression).
History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual
current and historical).
Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant
(gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used),
types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any
sexual concerns.
ROS: This covers all body systems that may help you include or rule out a differential
diagnosis. You should list each system as follows: General: Head: EENT: and so forth.
You should list these in bullet format and document the systems in order from head to
toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears,
Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No
palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain
or blood.
© 2022 Walden University, LLC
NRNP 6552: Advanced Nurse Practice in Reproductive Health Care
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or
tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or
polydipsia.
GENITOURINARY/REPRODUCTIVE: Burning on urination. Pregnancy. LMP:
MM/DD/YYYY. Breast-lumps, pain, discharge? No reports of vaginal discharge, pain?.
sexually active?
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam: From head to toe, include what you see, hear, and feel when conducting your
physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and
history. Do not use WNL or normal. You must describe what you see. Always
document in head-to-toe format (i.e., General: Head: EENT:).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop
the differential diagnoses (support with evidenced and guidelines).
A.
Primay and Differential Diagnoses (list a minimum of 3 differential diagnoses). Your
primary or presumptive diagnosis should be at the top of the list. For each diagnosis,
provide supportive documentation with evidence-based guidelines.
P.
Includes documentation of diagnostic studies that will be obtained, referrals to other
health care providers, therapeutic interventions, education, disposition of the patient,
and any planned follow-up visits. Each diagnosis or condition documented in the
assessment should be addressed in the plan. The details of the plan should follow an
orderly manner. Also included in this section is the reflection. The student should
reflect on this case and discuss whether or not they agree with their preceptors
treatment of the patient and why or why not. What did they learn from this case? What
would they do differently?
© 2022 Walden University, LLC
NRNP 6552: Advanced Nurse Practice in Reproductive Health Care
Also include in your reflection a discussion related to health promotion and disease
prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and
other risk factors (e.g., socioeconomic, cultural background).
References
You are required to include at least three evidence-based, peer-reviewed journal
articles or evidenced-based guidelines that relate to this case to support your
diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition
formatting.
© 2022 Walden University, LLC
Purchase answer to see full
attachment
Description
Case Study: Postmenopausal Bleeding
Thelma Smith is a 58-year-old African American female who presents to the office with the complaint of brown discharge for several days last week. Her medical history is remarkable for type 2 diabetes somewhat controlled with glipizide and metformin (last A1C 7.5). She is a G0, having never been able to get pregnant. She is up to date with mammograms and has had a colonoscopy 1 year ago, all normal. Her pap history is normal with her last pap 2 years ago reported an NILM HPV negative, atrophic changes, no endocervical cells noted.
Vital signs temperature 98.1 BP 140/88, pulse 82, respirations 12. She is 56 and 272 lbs. (BMI 43.90). Focused exam:
- Abdomen: soft, obese, + BS
- VVBSU: brown discharge noted,
- Cervix: brown blood noted coming from os, no cervical motion tenderness
- Uterus: unable to assess due to body habitus
- Adnexa: unable to assess due to body habitus
- Based on your assigned case study, post a Focused SOAP NOTE with the following:
-
- Differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.
- Define what you believe is the most important diagnosis. Be sure to include the first priority in conducting your assessment.
- Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint): This is a brief statement identifying why the patient is here in the
patients own words, for instance, headache, not bad headache for 3 days.
HPI: This is the symptom analysis section of your note. Thorough documentation in this
section is essential for patient care, coding, and billing analysis. Paint a picture of what
is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to
start every HPI with age, race, and gender (e.g., 34-year-old African American female).
You must include the seven attributes of each principal symptom in paragraph form, not
a list. If the CC was headache, the LOCATES for the HPI might look like the following
example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable
but not completely better
Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for
use. Also include over-the-counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a
description of what the allergy is (e.g., angioedema, anaphylaxis). This will help
determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major
illnesses, and surgeries. Depending on the CC, more info is sometimes needed.
© 2022 Walden University, LLC
NRNP 6552: Advanced Nurse Practice in Reproductive Health Care
Soc & Substance Hx: Include occupation and major hobbies, family status, vaping,
tobacco and alcohol use (previous and current use, how many times a day, how many
years), and any other pertinent data. Always add some health promotion questions
here, such as whether they use seat belts all the time or whether they have working
smoke detectors in the house, the condition of the living environment, text/cell phone
use while driving, and support systems available.
Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic
illnesses. The reason for death of any deceased first-degree relatives should be
included. Include parents, grandparents, siblings, and children. Include grandchildren if
pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression).
History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual
current and historical).
Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant
(gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used),
types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any
sexual concerns.
ROS: This covers all body systems that may help you include or rule out a differential
diagnosis. You should list each system as follows: General: Head: EENT: and so forth.
You should list these in bullet format and document the systems in order from head to
toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears,
Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No
palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain
or blood.
© 2022 Walden University, LLC
NRNP 6552: Advanced Nurse Practice in Reproductive Health Care
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or
tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or
polydipsia.
GENITOURINARY/REPRODUCTIVE: Burning on urination. Pregnancy. LMP:
MM/DD/YYYY. Breast-lumps, pain, discharge? No reports of vaginal discharge, pain?.
sexually active?
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam: From head to toe, include what you see, hear, and feel when conducting your
physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and
history. Do not use WNL or normal. You must describe what you see. Always
document in head-to-toe format (i.e., General: Head: EENT:).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop
the differential diagnoses (support with evidenced and guidelines).
A.
Primay and Differential Diagnoses (list a minimum of 3 differential diagnoses). Your
primary or presumptive diagnosis should be at the top of the list. For each diagnosis,
provide supportive documentation with evidence-based guidelines.
P.
Includes documentation of diagnostic studies that will be obtained, referrals to other
health care providers, therapeutic interventions, education, disposition of the patient,
and any planned follow-up visits. Each diagnosis or condition documented in the
assessment should be addressed in the plan. The details of the plan should follow an
orderly manner. Also included in this section is the reflection. The student should
reflect on this case and discuss whether or not they agree with their preceptors
treatment of the patient and why or why not. What did they learn from this case? What
would they do differently?
© 2022 Walden University, LLC
NRNP 6552: Advanced Nurse Practice in Reproductive Health Care
Also include in your reflection a discussion related to health promotion and disease
prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and
other risk factors (e.g., socioeconomic, cultural background).
References
You are required to include at least three evidence-based, peer-reviewed journal
articles or evidenced-based guidelines that relate to this case to support your
diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition
formatting.
© 2022 Walden University, LLC
Purchase answer to see full
attachment
General APA writing tips
Your paper must be double-spaced typed and formatted on standard-sized paper which is
(8.5″ x 11″), with 1 margins in all the four sides. Always type using a clear font that is visible and highly readable. It is recommend to us 12pt. Times New Roman font for APA paper format.
Your paper should have four main sections namely title page, abstract, main body, as well as the references page.
Title page: This section carries the paper title, name of the author, and the name of the institution.In this section include the page header on the left with the page number on the right at top.Note that your header should look like this Running head:PAPER TITLE.
Subsequent pages should have a header that look like this TITLE OF YOUR PAPER.
Reference page: write the word References on a new page at the top. Bold and centre the word. Put all the references alphabetically under the labeled title References. Remember to apply hanging indent whereby the first line of the reference is aligned to the left, and all other lines get indented 0.183 inches.
You can always count on us to write an original content that is plagiarism free and format your essay in APA, MLA, HAVARD, CHICAGO or any other format that your assignment require to be formatted in.
