With the information provided, you will learn what a nursing SOAP note is and also get to obtain clear guidelines based on how you can come up with a SOAP note assessment. Nurses and other healthcare professionals are required to have clear feedback based on how to come up with a SOAP note. Therefore, one should ensure that they can come up with a SOAP note that clearly captures information that is pertinent to the patient’s health.
At first, it is important to understand what a nursing SOAP note entails. The term SOAP usually comprises an acronym that stands for, Subjective, Objective, Assessment, and Plan. These four sections must be completed with entirety that is critical in coming up with a well-detailed SOAP note. Each of these four sections of the nursing SOAP note will be covered and the information that is presented in each section clearly illustrated.
Prior to examining details regarding the four parts of a SOAP note, it is also important to look at the purpose of a nursing SOAP note.
The Significance of a Nursing Soap Note
A nursing soap note is usually helpful in the diagnosis and treatment of a patient. The soap note is usually applied as a diagnosis tool that makes it possible to obtain the information that is relevant to making a diagnosis. By effectively applying the SOAP note, it is usually possible to determine the conditions that can be considered for diagnosis and even come up with appropriate recommendations given the information that is featured regarding a patient’s health.
When used for learning purposes, a nursing SOAP note usually facilitates learning and equips a student with the insight that can be critical in coming up with a nursing SOAP note. Students are usually presented with patient scenarios where they have to assess a student and even determine the conditions that can be considered for diagnosis.
While conducting the assessment, it is necessary to consider information about a patient’s health history and even about the symptoms that are currently exhibited. Also, one has to ensure that they obtain all the relevant information including details about the symptoms that they patient may be exhibiting at the moment. By obtaining these details, it is usually possible to obtain information regarding the underlying illnesses and even coming up with appropriate recommendations.
With this insight, the following are detailed guidelines on how to write a nursing SOAP note where clear examples have been provided.
Introduction Section of the Nursing SOAP note
This section of the SOAP note usually requires an individual to provide information regarding the conditions that may be underlying in the patient. For instance, a patient may be presenting for a mental health assessment where brief information regarding mental health assessment can be discussed. One can also provide general information regarding a patient’s health.
Subjective Section of the Nursing SOAP note
This is the first section of a nursing SOAP note where one has to provide information regarding the patient health and social history. The information that is obtained in this section is very important since it makes it possible to understand the condition that is underlying in the patient. At first, one must begin by identifying the chief complaint which is the main issue that is presented in the patient. For instance, given the example that is featured, it is evident that the chief complaint is cherry red papules on the skin.
The information that is featured in the subjective section of a nursing SOAP note usually comprises the information that a patient shares regarding their health.
To obtain further insight into the information that should be featured in the subjective section of a nursing soap note, you can also consider reviewing the information provided by Wolters Kluwer regarding writing a SOAP note.
Chief Complaint (CC): Cherry red papules on the skin.
History of Present Illness (HPI): Mr. Smith is a 35-year-old white male who presents himself today with a skin condition characterized by cherry red papules of the skin. The red papules were of various sizes and based on the feedback given by the patient, the condition had persisted for almost two years (See Appendix 1). The symptoms were gradual considering that papules began as smalls red dots that eventually increased in size taking a raised and round shape of a dome. Judging by the appearance of the patient’s chest and abdomen, more dots were coming up as others increased in size. The condition seemed quite severe considering the number of papules that had developed on the skin. Initially, Mr. Smith has consulted a physician where it became clear that the condition was harmless. However, no medication was initially prescribed but with the increase in the papules, he therefore, decided to seek further treatment.
Based on the underlying condition, no medication had initially been administered. However, considering other underlying medical conditions, some of the medications taken included;
- chlorothiazide (Diuril) daily
- lisinopril twice per day
- metformin thrice and after meals
- glipizide thrice and after meals
Allergic to eggs and cow’s milk- causes itching pimples
Past Medical History (PMH):
The patient has a history of diabetes and hypertension. However, the conditions are in control and he is consistently taking medications.
Past Surgical History (PSH):
Proper sex performance
Regularly exercises and goes to the gym twice a week.
Drinks on average 5 bottles of beer over the weekend.
All the immunizations are up to date. He received an influenza and a tetanus vaccine in the previous vaccine.
Significant Family History:
The grandparents have a history of hypertension and high blood pressure. A distant cousin has also exhibited a similar skin condition.
Mr. Smith currently works as an educator and is married with two children. He lives in the city where teaches in a high school. The area has tight security with essential social amenities and infrastructure. He receives a good salary and also has a stable medical insurance cover. He is a member of the local church and he also runs a couple of businesses in the area. Often, he enjoys going out with his family and to visit his parents who live in the suburbs.
Review of Systems:
General: There are no severe physiological signs that have come up which are associated with the condition. For instance, Mr. Smiths weight has remained constant. No serious signs such as fever that are associated with serious medical issues.
HEENT: There are no associated changes in vision and hearing. Mr. Smith does not experience any issue hearing or even reading. No symptoms associated with the head have occurred such recently such as headaches and even dizziness. However, he recently experienced a little tickle in his throat and a running nose that was associated with a flu that eventually ended in three days with no medication.
Neck: No pain or papules were identified in the neck region.
Breasts: Papules identified in the area around the breasts.
Respiratory: Normal breathing is exhibited. No coughs and other complications associated with the respiratory system.
Cardiovascular/Peripheral Vascular: normal pulse rate was identified as 90 beats per minute.
Gastrointestinal: No stomach complications such as vomiting, abdominal pain, and constipation among others were exhibited. Normal bowel movements were also exhibited.
Genitourinary: The urinary pattern was normal and other complications associated with the urinary tract system were not exhibited. Also, no STIs or infections were identified in the genital areas.
Musculoskeletal: The musculoskeletal system was working effectively. The muscles, joints, ligaments, tendons, and cartilages were all working in the right way. Symptoms of condition such as arthritis were also negative.
Psychiatric: The patient denied having stress and anxiety. However, based on the assessment, it was clear that the patient was experiencing intense thoughts as a result of the condition. For instance, he was deeply worried that the condition may not end and that it may turn out be severe.
Neurological: The patient was free from all the neurological disorders. No signs of dizziness, loss of sight, persistent headache, lack of coordination, and even the loss of memory were exhibited.
Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.
As explained, the patient had cherry red papules of the skin. The papules had been growing gradually and increasing in size and as a result, the patient was forced to seek medical attention.
No underlying disorders associated with the blood or the blood forming organs were identified.
One endocrine disorder identified in the patient was diabetes. However, the thyroid glands along with other glands that make up the endocrine system were of normal size (not swollen) that was an indicator that the body was free from infections.
Although the individual was allergic to eggs and the cow’s milk, no allergies were exhibited at the time.
Objective Section of the Nursing SOAP note
While coming up with a nursing SOAP note, one usually provides their own perception regarding the symptoms that are presented in the patient. Generally, one usually provides information based on the question they ask the patient and even what they observe.
Vital signs: B/P: 113/74 Wt: 134 lbs; Ht: 5’2; BMI 19
General: The patient appeared healthy but distressed. His gait, posture, and motor activity were normal. His grooming and hygiene were excellent considering that she was smartly dressed with no odors and unpleasant breath.
HEENT: No tumors, masses or abnormal swellings were identified on his head. The patient also exhibited proper vision and no concerns were identified with his ears, nose, and throat.
Neck: No glandular or the enlargement of the thyroid was identified. No masses.
Chest/Lungs: Normal breathing was exhibited. No abnormal sounds that could be a sign of obstruction in the airways were identified.
Heart/Peripheral Vascular: Normal pulse rate (75-80 beats per minute)
Abdomen: Normal bowel sounds and movements.
Genital/Rectal: No masses or signs of genitalia and rectal infection
Musculoskeletal: No swellings, redness, and even pain that was exhibited in the joints, muscles, and the bones. Proper body movement was also exhibited.
Neurological: proper motor function was exhibited, coordination, and even the mental status.
Skin: Present of the red papules on the skin.
Assessment Section of the Nursing SOAP Note
Based on the assessment that has been conducted, the following diagnosis was made:
- Cherry Angiomas:
This examination identifies the condition as Cherry Angiomas. The condition is usually characterized by round to oval shaped papules that have sizes that range from pin point to several millimeters (Gunn, 2018).
- Herpes Zoster:
This condition could also serve as a diagnosis for the condition that has been exhibited. The condition exists as a type of herpes virus that is presented as a small vesicle filled with a fluid (CDC, 2020).
- capillary hemangioma
This condition could also be determined as capillary hemangioma. The condition is presented as an abnormal growth of tiny capillaries that can occur in any place on the body (Medscape, 2020).
Diagnosis: Based on the signs that have been exhibited and the symptoms expressed, the patient is most likely suffering from Cherry Angiomas. This condition exists in form of skin growths that contain a collection of blood capillaries inside the papules that are exhibited. The condition is normally found in individuals that are 30 years and older and is not associated with serious concerns unless bleeding occurs. There are no medications that can be used to treat this condition. However, some of the methods that may be used for treatment include electrocauterization, cryosurgery, and laser surgery (Delgado, 2018). At first, electrocauterization involves burning the angioma using through the use of an electric current that is delivered through a tiny probe. The second method this is cryosurgery involves freezing the angioma with liquid nitrogen. Laser surgery usually involves the use of a pulsed dye laser to get rid of the cherry angioma. Therefore, one of these treatment alternatives could be applied in this case.
Plan Section of the Nursing SOAP note
This section is important since it provides guidelines based on the activities that have to be undertaken to promote recovery in the patient. To effectively come up with this part, one must ensure that they diagnose the underlying condition with clarity.
The reflection is very important for one’s professional growth and even for the wellbeing of the patient. While coming up with a reflection, one should ensure that they provide their thoughts regarding the lessons learned and even what they may have observed or even thoughts elicited. While coming up with this section of a nursing SOAP note, one also has to capture information regarding how the lesson learned can influence their future practice.
This section helps to bring closure to the nursing SOAP note since a summary of the main issues that came up and the actions that were taken is provided.
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