SOAP Note Sample Format For MRC - LP, Date, Time 1315 ✓ Solved
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SOAP NOTE SAMPLE FORMAT FOR MRC Name: LP Date: Time: 1315
SOAP Note Sample Format for MRC:
Subjective:
CC: "I am having vaginal itching and pain in my lower abdomen." HPI: Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks...
Objective:
Weight 140lb Temp -97.7 BP 123/82 Height 5'4" Pulse 74 Respiration 18 General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately...
Assessment:
Differential Diagnoses: 1-Bacterial Vaginosis (N76.0), 2-Malignant neoplasm of female genital organ, unspecified. (C57.9), 3-Gonococcal infection, unspecified. (A54.9). Diagnosis: Urinary tract infection, site not specified. (N39.0) Candidiasis of vulva and vagina. (B37.3)...
Plan/Therapeutics: Medication – Terconazole cream 1 vaginal application QHS for 7 days for Vulvovaginal Candidiasis; Sulfamethoxazole/TMP DS 1 tablet PO twice daily for 3 days for UTI...
References: Colgan, R. & Williams, M. (2011). Diagnosis and Treatment of Acute Uncomplicated Cystitis. American Family Physician, 84 (7), ... Hainer, B. & Gibson, M. (2011). Vaginitis: Diagnosis and Treatment. American Family Physician, 83 (7), ... Woo, T. M., & Wynne, A. L. (2012). Pharmacotherapeutics for Nurse Practitioner Prescribers (3rd ed.). Philadelphia, PA: F.A. Davis Company.
Paper For Above Instructions
SOAP notes play a vital role in clinical documentation and provide a structured way to communicate patient information among healthcare providers. This paper discusses the format of a SOAP note by leveraging a case study designed to illustrate how to methodically document patient data, subjective and objective findings, assessments, and plans for treatment.
Introduction
SOAP (Subjective, Objective, Assessment, Plan) notes are essential in various healthcare settings. They help maintain continuity of care, enhance collaboration among providers, and ensure accurate documentation of patient interactions. This paper provides a detailed explanation of a SOAP note format and exemplifies it with a patient case.
Subjective Findings
The subjective section of the SOAP note captures the patient's reports regarding their symptoms, feelings, concerns, and perceptions. In the provided case, the patient, a 30-year-old African American female, presents with symptoms of vaginal itching and lower abdominal pain. The patient reports unsuccessful self-treatment attempts and expresses concern regarding possible infections such as a urinary tract infection (UTI) or sexually transmitted infections (STIs).
Significantly, the history of present illness (HPI) details the duration and character of the symptoms. The patient notes that the vaginal itching and burning during urination have persisted for three weeks. The abdominal pain, described as both sharp and dull, has been intermittent. It's crucial to note that the patient denies fever and reports no aggravating factors for her pain, which guides the clinician's differential diagnosis (Colgan & Williams, 2011).
Objective Findings
The objective portion of the SOAP note includes measurable, observable data from physical examinations and tests. The physical exam for this patient revealed a healthy-appearing adult female without acute distress but with specific findings suggesting a UTI. Vital signs recorded include a stable BP of 123/82 and other relevant assessments such as a normal skin examination and tenderness in the suprapubic area during the abdominal exam. Further laboratory tests, including urinalysis, showed blood (likely from the menstrual cycle) but were negative for infection (Hainer & Gibson, 2011).
Assessment
The assessment section synthesizes findings from the subjective and objective components to arrive at a working diagnosis. In this case, several differential diagnoses were considered, including Bacterial Vaginosis, Gonococcal infection, and urinary tract infection. The final diagnosis concluded with a urinary tract infection along with candidiasis of the vulva and vagina based on the symptoms and examination (Woo & Wynne, 2012).
Plan
The plan outlines the proposed treatment and management for the patient. For this case, the clinician prescribed Terconazole cream for candidiasis and sulfamethoxazole/trimethoprim (TMP) for the UTI. The patient was educated on the medications, potential complications, preventive measures, and the importance of returning for follow-up tests (Colgan & Williams, 2011). This section of the SOAP note is crucial as it not only provides treatment direction but also involves patient education, which is key for effective healthcare outcomes.
Conclusion
SOAP notes are an integral part of medical documentation, crucial for effective patient management and healthcare recurrence. By utilizing a clear structure that separates subjective experiences from objective observations, healthcare providers can ensure thorough and accurate assessments, leading to informed treatment decisions. This format supports both patient-centered care and effective communication among healthcare teams.
References
- Colgan, R., & Williams, M. (2011). Diagnosis and Treatment of Acute Uncomplicated Cystitis. American Family Physician, 84(7), ...
- Hainer, B., & Gibson, M. (2011). Vaginitis: Diagnosis and Treatment. American Family Physician, 83(7), ...
- Woo, T. M., & Wynne, A. L. (2012). Pharmacotherapeutics for Nurse Practitioner Prescribers (3rd ed.). Philadelphia, PA: F.A. Davis Company.
- Domino, F., Baldor, R., Golding, J., & Stephens, M. (2017). The 5-Minute Clinical Consult.
- Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
- Jameson, J. L., & Fauci, A. S. (2020). Harrison's Principles of Internal Medicine (20th ed.). New York, NY: McGraw-Hill.
- American Urological Association. (2015). Diagnosis and Treatment of UTI.
- CDC. (2021). Sexually Transmitted Infections Treatment Guidelines.
- Wen, S. W., et al. (2016). Trends in Vulvovaginal Candidiasis among Women in the United States.
- Higgins, M. W., & Drennan, J. (2018). Cardiovascular and Renal Complications of Hypertension.
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