Instructions

Over the course of the semester you will choose 10 patient encounters to document an extended SOAP note for.

It is expected that you vary the primary focus of each note to ensure you are receiving quality feedback for several types of patient encounters to include acute, chronic and wellness encounters. You are not to utilize the same type of encounter, acute/chronic health condition or wellness exam, more than once unless you have received approval to do so from your clinical faculty person.

Each SOAP note carries a 15-point value.

SOAP notes will be evaluated using a standardized rubric. Please review the evaluation criterion to ensure that your SOAP notes are constructed to address the required elements and desired level of achievement.

For planned weekly clinical experiences submission of the 10 SOAP notes would be accomplished by submitting one SOAP note weekly for weeks 4 through week 13.

For planned and approved condensed, compressed or alternate clinical experiences, submission of the 10 SOAP note would be dependent on the approved clinical schedule. This may mean that more than 1 SOAP note would need to be submitted on a weekly basis. If you are not in clinical for weeks where a SOAP note is due a 0 will be input into the Grade Center as a place holder until you have submitted the required assignment.

Patient: 50-year-old female

Date: [Insert Date]

Location: Primary Care Clinic

Chief Complaint:

Sore throat, cough, congestion, and fatigue.

S Subjective

HPI:

50-year-old female presents to clinic with complaints of sore throat, cough, nasal congestion, and fatigue for approximately 45 days. Patient reports gradual onset of symptoms. Cough is mostly dry but occasionally productive of clear mucus. She reports throat irritation with swallowing and generalized fatigue. Nasal congestion and postnasal drainage are also present.

Patient denies chest pain, severe shortness of breath, wheezing beyond baseline, hemoptysis, nausea, vomiting, or diarrhea. No recent travel reported. Patient states symptoms have not improved with over-the-counter cold medications.

Given persistence of symptoms and worsening fatigue, patient presents for evaluation and treatment.

Past Medical History:

• Hypothyroidism
• Rheumatoid arthritis
• Fibromyalgia
• Epilepsy/seizure disorder
• Asthma

Current Medications (per chart review):

Examples from medication history include:

• Albuterol sulfate inhaler PRN
• Albuterol nebulizer solution PRN
• Ipratropium-albuterol nebulizer solution
• Lamotrigine
• Levothyroxine 75 mcg daily
• Liothyronine 5 mcg daily
• Clonazepam
• Dextroamphetamine-amphetamine
• Mirtazapine

These medications appear in the patient medication record shown in the attached chart images.

SOAP meds.1

SOAP meds.2

Allergies:

Not documented

Review of Systems

Constitutional:

Fatigue present. Denies fever or chills.

HEENT:

Sore throat, nasal congestion, postnasal drainage.

Respiratory:

Cough present. Denies severe shortness of breath.

Cardiovascular:

Denies chest pain or palpitations.

GI:

Denies nausea, vomiting, diarrhea.

Neurological:

Denies dizziness or syncope.

O Objective

Vital Signs:

[Insert vitals]

General:

Alert, oriented, mildly ill appearing but in no acute distress.

HEENT

Head: Normocephalic

Eyes: PERRLA, conjunctiva clear

Nose: Nasal mucosa erythematous with congestion

Throat: Mild pharyngeal erythema, no tonsillar exudate

Neck:

Supple, mild anterior cervical lymphadenopathy

Lungs:

Clear to auscultation bilaterally

No wheezes, rales, or rhonchi noted

Cardiovascular:

Regular rate and rhythm, no murmurs

Skin:

Warm and dry

A Assessment

1. Acute upper respiratory infection
2. Acute bronchitis with cough
3. Pharyngitis
4. History of asthma
5. Hypothyroidism
6. Rheumatoid arthritis
7. Fibromyalgia
8. Epilepsy

P Plan

Medications Prescribed Today

• Prednisone 40 mg PO daily x 5 days
• Azithromycin
• Day 1: 500 mg PO once
• Day 25: 250 mg PO once daily

Supportive Care

• Increase fluid intake
• Rest
• OTC acetaminophen or ibuprofen PRN fever or throat discomfort
• Warm saltwater gargles
• Humidifier use if needed

Asthma Management

• Continue rescue inhaler as needed
• Monitor for worsening respiratory symptoms

Patient Education

• Discussed likely infectious respiratory illness
• Complete full antibiotic course
• Monitor for worsening symptoms including:
• fever
• shortness of breath
• chest pain
• persistent cough

Follow-Up

• Return if symptoms worsen or fail to improve in 57 days
• ER precautions given for respiratory distress