Must Use The Sample Template For Your SOAP Note Use APA Form ✓ Solved

Must Use The Sample Template For Your Soap Noteuse APA Format And Mus

Must use the sample template for your SOAP note, use APA format, and include a minimum of 2 scholarly citations. The Patient History, Chief Complaint (CC), History of Present Illness (HPI), Assessment, and Plan should be original work, individualized to a hypothetical patient. Turnitin score must be less than 15%, indicating the work is original and in your own words.

Sample Paper For Above instruction

Introduction

Creating an accurate and individualized SOAP (Subjective, Objective, Assessment, and Plan) note is an essential skill for healthcare practitioners. This type of documentation ensures comprehensive patient care, facilitates effective communication among healthcare providers, and supports legal and continuity of care. The use of standardized templates, adhering to APA formatting, and integrating scholarly literature enhances the professionalism and credibility of clinical documentation.

Patient History and Chief Complaint

The patient, a 45-year-old male, presents with a primary complaint of persistent lower back pain lasting for three weeks. The patient reports that the pain is dull, constant, and occasionally radiates to the left thigh. He describes the onset as gradual, with no clear history of trauma, and rates the pain as 6 out of 10 on the pain scale. The patient reports increased discomfort after prolonged sitting and during physical activity, with some relief when resting. No associated symptoms such as numbness, weakness, fever, or weight loss were reported.

The patient's medical history reveals hypertension managed with lisinopril and hyperlipidemia. He reports no previous episodes of similar back pain, no history of spinal injury, and no current use of narcotics or anti-inflammatory medications. Family history includes hypertension and coronary artery disease. The patient is a non-smoker and consumes alcohol socially. His lifestyle indicates a sedentary work routine with minimal regular exercise.

History of Present Illness

The patient's back pain began insidiously approximately three weeks ago. He initially attributed it to prolonged sitting at work but noted that the pain gradually worsened despite over-the-counter pain relievers. The pain is localized in the lower lumbar region, characterized as aching, with intermittent sharp sensations during specific movements. There has been no associated urinary or bowel incontinence, fever, or unexplained weight loss. The patient reports that the pain increases after physical activities such as lifting or bending and improves with rest. He denies any recent trauma, strenuous activity, or known injury.

The patient mentions that previous episodes of back discomfort occurred intermittently over the past year but were less severe and resolved spontaneously. He has not sought medical attention for prior episodes. He has tried over-the-counter NSAIDs without significant relief. No current use of prescription medications for back pain.

Assessment

The clinical impression is consistent with mechanical low back pain, likely due to lumbar strain or degenerative disc disease, given the patient's history, symptom pattern, and absence of red flag symptoms (Maher et al., 2017). The patient's risk factors include sedentary lifestyle, obesity (BMI 29 kg/m²), and age-related degenerative changes. Differential diagnoses include disc herniation, spinal stenosis, and less likely, malignancy or infection, but these are less probable given the current history and presentation.

Physical examination reveals localized tenderness over the lumbar paraspinal muscles, mild decreased range of motion in lumbar flexion and extension, and no abnormal neurological findings such as weakness or sensory deficits. Straight leg raise test was negative, ruling out significant nerve root compression.

Laboratory tests are not indicated at this stage, but imaging might be considered if symptoms worsen or neurological signs develop.

Plan

The management plan involves conservative treatment with patient education on posture and ergonomics, encouraging regular activity within pain limits, and initiating physical therapy focusing on strengthening and flexibility exercises (Denhart et al., 2016). NSAIDs such as ibuprofen 400 mg three times daily are recommended for pain relief. The patient is advised to avoid prolonged bed rest and to maintain activity as tolerated.

Follow-up is scheduled in four weeks to assess symptom progression. If symptoms persist or worsen, further investigations like lumbar spine X-ray or MRI should be considered to evaluate for structural abnormalities, discogenic pathology, or other underlying conditions. Patient education regarding warning signs requiring immediate medical attention—such as weakness, loss of bladder or bowel control—is emphasized. Addressing modifiable risk factors like weight management and encouraging physical activity are essential components of long-term care.

Conclusion

Effective documentation of patient encounters through SOAP notes supports evidence-based practice and improves patient outcomes. Following a structured template, adhering to APA format, and ensuring originality in subjective and assessment components contribute to high-quality clinical records.

References

Denhart, K., Brossart, D., & Yim, J. (2016). The role of physical therapy in managing low back pain. Journal of Orthopaedic & Sports Physical Therapy, 46(5), 361-370. https://doi.org/10.2519/jospt.2016.6376

Maher, C. G., Underwood, M., & Buchbinder, R. (2017). Non-specific low back pain. The Lancet, 389(10070), 736-747. https://doi.org/10.1016/S0140-6736(16)30970-9

Smith, J. A., & Johnson, L. M. (2020). Conservative management of lumbar spine disorders. Spine Health Journal, 15(3), 125-132.

Williams, R., & Clark, M. (2018). Diagnostic approaches for low back pain. Pain Medicine Reviews, 23(2), 129-136.

Brown, S., & Nguyen, P. (2019). Impact of sedentary lifestyle on musculoskeletal health. Journal of Physical Therapy Science, 31(4), 573-578.

Wilson, P. R., & Adams, M. M. (2021). Imaging recommendations for low back pain. Radiology Today, 22(6), 34-41.

Garfield, J., & Steffens, D. (2019). Red flags and yellow flags in low back pain management. Clinical Orthopaedics and Related Research, 477(6), 1291-1298.

Kumar, S., & Gupta, R. (2022). Role of lifestyle modifications in the management of chronic back pain. European Journal of Physical and Rehabilitation Medicine, 58(2), 242-248.

Lee, H., & Kim, S. (2020). Patient education and adherence in back pain management. International Journal of Evidence-Based Healthcare, 18(4), 275-282.

Peterson, D., & Lee, M. (2019). Evidence-based guidelines for low back pain. American Journal of Physical Medicine & Rehabilitation, 98(5), 370-378.