soap note pt 2
review by rubric and add references
a year ago 9
MSNSoapNoteRubricElsaPreceptor.pdf
SoapNotetrachandStentPatient.docx
MSNSoapNoteRubricElsaPreceptor.pdf
SOAP NOTE RUBRIC
Criteria Points Competent Need Improvement Not Acceptable
Score
Subjective (35 points) Provides complete, concise, and accurate information, which is well organized and easy to understand.
Provides most of the pertinent information, but is not well organized and/or is slightly challenging to understand. May be missing pertinent negative information (e.g., patient denies…).
Limited or no summary of pertinent information, is organized poorly, contains inaccurate information, and/or is difficult to understand.
Chief complaint 5 5 3 1 HPI 10 10 8 6 Relevant PMH & FH 5 5 3 1 ROS 10 10 8 6 Currents: Allergies, Meds/OTCs, Tobacco, Immunizations, Diet, Exercise, Sleep
5 5 3 1
Objective (40 points) Provides complete, concise, and accurate information, which is well organized and easy to understand.
Provides most of the pertinent information, but is not well organized and/or is slightly challenging to understand. May be missing pertinent negative information (e.g., patient denies)
Limited or no summary of pertinent information, is organized poorly, contains inaccurate information, and/or is difficult to understand.
General survey (Describe the state of the patient at the time of the examination)
10 10 8 6
Vital signs Height, Weight, BMI
10 10 8 6
Physical exam-systematic, organized and thorough and related to the reason of the visit
20 20 18 16
Diagnosis/ Differentials Diagnosis (10 points)
Main diagnosis/ Differentials Diagnosis is supported by the objective and subjective assessment and rationale for choosing the
Main diagnosis/ Differentials Diagnosis is supported by the objective and subjective assessment but the rationale for choosing the diagnosis is not
Main diagnosis/ Differentials Diagnosis is not supported by the objective and subjective assessment and the rationale for choosing the
SOAP NOTE RUBRIC
diagnosis is supported by the evidence
supported by the evidence
diagnosis is not supported by the evidence
Diagnosis/(Assessment) 5 5 3 1 List of differentials supported by S+O findings (5 points) Must provide 3 differential diagnoses with one citation for each diagnosis.
5 5 3 1
Plan of care (10 Points) Complete and appropriate plan for the main problem and other active problems. Includes pharmacologic and/or non- pharmacologic and/or complete sig components.
Mostly complete and appropriate plan for the main problem and other active problems. May be missing appropriate non-pharmacologic treatments and/or sig components.
Missing or inappropriate treatment plan for the main problem and other active problems.
Diagnostic tests/therapies/medications
5 5 3 1
Follow-up/Pt. Education and Health Promotion
5 5 3 1
References (5 Points) Provides a complete and appropriate list of references that are in APA format.
References listed are appropriate (i.e. guidelines or primary), but not complete and some may be missing. Not APA formatted.
References missing or very limited. References listed are inappropriate (i.e. tertiary) and/or not relevant.
References 5 5 3 1 Total 100
Comment:
SoapNotetrachandStentPatient.docx
|
Patient Initials: MR |
Pt. Encounter Number: 2-5 |
|
|
Date: 1/15/2025 |
Age: 70 y.o |
Sex: Male |
|
Allergies: NKA Advanced Directives: On File
|
||
|
SUBJECTIVE |
||
|
CC: Nurse from Step down reports increased Shortness of breath, sputum production, labored breathing, hypoxia and fever. |
||
|
HPI: 70 year old male presents to the hospital with shortness of breath, cough and fever for 5 days. Today with worsening dyspnea, reports increased thick yellow secretions through tracheostomy and hypoxia. Hx of HIV, multinodular goiter, COPD, tracheal compression most likely due to extrinsic compression due to enlarged thyroid s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25. Pt was transferred to ICU do to hypoxemic respiratory insufficiency, placed on Bipap overnight, switch to HFNC 40L/100, and stent migration to carina level that needed close monitoring in the ICU.
Onset: 5 days ago Location: Chest Discomfort with Inspiration, throat pain Duration: Intermittent Characteristics: Sore throat, sore back and chest. Aggravating Factors: While coughing. When Laying Flat Relieving Factors: Respiratory treatments, Sleeping with HOB elevated, Suctioning. Treatment: CT ABD Scan STAT ordered, Surgical team on board, labs CBC, BMP, Aptt, PT/INR, blood cx. Close monitoring in ICU.
|
||
|
Current Medications: Albuterol 180 mcg Inhaler, Mucomyst 200 mg/ml solution 600 mg, Ipratropium-albuterol (Duoneb) 0.5 mg-3 mg Neb Solution, Cefepime 2 G in sodium chloride 0.9 % 100 ml IVPB, Peridex 0.12 % solution 15 ml. Solumedrol 60 mg IV push Insulin regular 100 unit/ml Sliding scale. Cardura 4 mg HS Flomax 0.4 mg QD Pantoprazole 40 mg IV Push QD Cobicistat 150 mg Tab, Darunavir 800 mg tab, Dolutegravir 50 mg tab. Precedex 400 mcg in sodium chloride 0.9 % infusion titrate as per orders. Lexapro 20 tab. Zyprexa 20 mg HS Zolpidem (Ambien) 10 mg Tab HS.
|
||
|
PMH: HIV, multinodular goiter, COPD, DM, BPH, Depression, Tracheostomy.
Medication Intolerances: None
Chronic Illnesses/Major traumas: HIV, COPD, IDDM
Screening Hx/Immunizations Hx: Up to Date, Influenza and Pneumococcal.
Hospitalizations/Surgeries:
s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25 |
||
|
Family History: Father-60 years old died from Lung Cancer. Mother-72 years old died from Heart Attack. |
||
|
Social History:
Patient comes from LTACH. Smoked in the past, denies alcohol or drug us. Non-Ambulatory. Requires frequent repositioning to prevent bedsores. Fall precautions and Aspiration precautions in place. |
||
|
ROS |
||
|
General
AAOx1. Appears fatigued and mild respiratory distress. |
Cardiovascular
· Hemodynamic monitoring and management. · Continue Cardura 4 mg. |
|
|
Skin
Normal, Warm and Dry. Good skin turgor. |
Respiratory
· Strict airway monitoring due to mass and stent migration to carina. · Continue Cefepime for multifocal PNA · HFNC, NRM w/ heliox treatment · Continue nebulizer · Keep FiO2 >92% · Suction PRN |
|
|
Eyes
Denies visual loss, blurred vision, or double vision. Denies history of cataracts or glaucoma. Uses glasses. |
Gastrointestinal
· NPO Status · Gi Px: Protonix
|
|
|
Ears
Denies recent infections, ear pain, or tinnitus. Hard of hearing. |
Genitourinary/Gynecological
No acute issues: Denies urinary urgency, frequency, dysuria, odorous urine, suprapubic pain. · Continue monitoring of renal function, I/O, and electrolytes. Replace PRN. · Maintenance IV Fluids at 50 ml/hr. · CKD (Baseline Cr 1.5) · Continue Flomax to prevent urinary retention. |
|
|
|
|
|
Nose/Mouth/Throat
Denies nasal pain, drainage, congestion, or other sinus issues. Denies throat pain or swelling. |
Musculoskeletal
ROM limited. Bedbound. · PT/OT ordered · OOB to Chair
|
|
|
Breast
Denies discharge, tenderness. No palpable mass during exam. |
Neurological
Sleeping, arousable upon calling. AAOx1 |
|
|
Heme/Lymph/Endo
· Afebrile · Leukocytosis · Continue HART Meds. · Pending OR this week for migrated Stent in the Carina. |
Psychiatric
· AAOx1 · Continue Lexapro 20 QD · Continue Zyprexa 20 mg and Ambien 10 mg HD · Titrate Precedex as ordered. |
|
|
OBJECTIVE |
||
|
Weight 167 lbs BMI 26.30 kg/m |
Temp 98.1 |
BP 107/57 |
|
Height 5’7” |
Pulse 65 |
Resp 20 |
|
PHYSICAL EXAMINATION |
||
|
General Appearance Patients currently sleeping, easy to arouse. Weakness, fatigued. No distress noted. Denies pain or discomfort at the moment. |
||
|
Skin Skin is intact, warm, dry, and adequate color. Normal skin turgor. Capillary refills < 3 seconds.
|
||
|
HEENT Head in normocephalic/atraumatic. Visual field full by confrontation. Conjunctiva pink, sclera white. Pupils 3 mm equally, round react to light and accommodation. EOM intact. No nose discharged noted. Fontal sinuses non-tender to palpation. No bleeding gum noted. Buccal mucosa dry, pink, and intact. Uvula midline, no exudate noted. Tracheostomy noted. No JVD noted. |
||
|
Cardiovascular Currently NSR. No murmurs noted upon auscultation. Denies Chest Pain. |
||
|
Respiratory Diminished breath sounds to auscultation bilaterally. No wheezing or stridor noted. Saturation 99-100 % on HFNC 40 L/100%. |
||
|
Gastrointestinal Abdomen soft, non-distended, round. Bowel sounds present. Last BM reported yesterday.
|
||
|
Breast No lumps noted on palpation. Symmetrical. |
||
|
Genitourinary No inguinal Hernias or CVA tenderness. Urine clear and yellow. Monitor I/O. |
||
|
Musculoskeletal Frequent repositioning. OOB to chair with PT. Weaknesses. Limited ROM. No cyanosis or pedal edema. |
||
|
Neurological AAOx1 to self, disoriented to situation, time, place. Speech clear. Following simple commands. Weakness BL upper and Lower extremities. Denies headache or dizziness. |
||
|
Psychiatric Patient with hx depression and anxiety. Calm and pleasantly confused at the moment. |
||
|
Lab Tests: CBC, BMP, aPtt, PT/INR, Blood cx, Urine Analysis, Sputum Cultures ABG to evaluate hypoxemia and hypercapnia. CD4 count and HIV viral load to assess immune status |
|
|
|
Special Tests: Surgical Consult, CT Chest and Neck w/o contrast, Chest Xray To asses for PNA and stent positioning. |
|
Diagnosis |
|
· Primary Diagnosis- · J96.01 - Acute Respiratory Failure with Hypoxia · Z93.0 Tracheostomy status · R09.02- Hypoxemia · R50.9- Fever, unspecified. · J38.4 – Edema of Larynx
o Differential Diagnoses : Acute COPD exacerbation. Thyroid-Related Airway Compression. Stent related Complications. Infectious Process likely bacterial tracheitis or Pneumonia.
o Plan: Daily CT chest and neck, Chest Xray, and Labs. · Possible emergent Bronchoscopy if stent causes obstruction. · Referrals for Pulmonology for airway management, Surgical Consult for multinodular goiter and removal of stent. ID following, and PT/OT to mobilize patient and prevent skin breakdown. Continue antibiotics, steroids and Nebulizers Tx. Education: NPO status, importance of repositioning |
|
References
|
SOAP NOTE
MSNSoapNoteRubricElsaPreceptor.pdf
SOAP NOTE RUBRIC
Criteria Points Competent Need Improvement Not Acceptable
Score
Subjective (35 points) Provides complete, concise, and accurate information, which is well organized and easy to understand.
Provides most of the pertinent information, but is not well organized and/or is slightly challenging to understand. May be missing pertinent negative information (e.g., patient denies…).
Limited or no summary of pertinent information, is organized poorly, contains inaccurate information, and/or is difficult to understand.
Chief complaint 5 5 3 1 HPI 10 10 8 6 Relevant PMH & FH 5 5 3 1 ROS 10 10 8 6 Currents: Allergies, Meds/OTCs, Tobacco, Immunizations, Diet, Exercise, Sleep
5 5 3 1
Objective (40 points) Provides complete, concise, and accurate information, which is well organized and easy to understand.
Provides most of the pertinent information, but is not well organized and/or is slightly challenging to understand. May be missing pertinent negative information (e.g., patient denies)
Limited or no summary of pertinent information, is organized poorly, contains inaccurate information, and/or is difficult to understand.
General survey (Describe the state of the patient at the time of the examination)
10 10 8 6
Vital signs Height, Weight, BMI
10 10 8 6
Physical exam-systematic, organized and thorough and related to the reason of the visit
20 20 18 16
Diagnosis/ Differentials Diagnosis (10 points)
Main diagnosis/ Differentials Diagnosis is supported by the objective and subjective assessment and rationale for choosing the
Main diagnosis/ Differentials Diagnosis is supported by the objective and subjective assessment but the rationale for choosing the diagnosis is not
Main diagnosis/ Differentials Diagnosis is not supported by the objective and subjective assessment and the rationale for choosing the
SOAP NOTE RUBRIC
diagnosis is supported by the evidence
supported by the evidence
diagnosis is not supported by the evidence
Diagnosis/(Assessment) 5 5 3 1 List of differentials supported by S+O findings (5 points) Must provide 3 differential diagnoses with one citation for each diagnosis.
5 5 3 1
Plan of care (10 Points) Complete and appropriate plan for the main problem and other active problems. Includes pharmacologic and/or non- pharmacologic and/or complete sig components.
Mostly complete and appropriate plan for the main problem and other active problems. May be missing appropriate non-pharmacologic treatments and/or sig components.
Missing or inappropriate treatment plan for the main problem and other active problems.
Diagnostic tests/therapies/medications
5 5 3 1
Follow-up/Pt. Education and Health Promotion
5 5 3 1
References (5 Points) Provides a complete and appropriate list of references that are in APA format.
References listed are appropriate (i.e. guidelines or primary), but not complete and some may be missing. Not APA formatted.
References missing or very limited. References listed are inappropriate (i.e. tertiary) and/or not relevant.
References 5 5 3 1 Total 100
Comment:
SoapNotetrachandStentPatient.docx
|
Patient Initials: MR |
Pt. Encounter Number: 2-5 |
|
|
Date: 1/15/2025 |
Age: 70 y.o |
Sex: Male |
|
Allergies: NKA Advanced Directives: On File
|
||
|
SUBJECTIVE |
||
|
CC: Nurse from Step down reports increased Shortness of breath, sputum production, labored breathing, hypoxia and fever. |
||
|
HPI: 70 year old male presents to the hospital with shortness of breath, cough and fever for 5 days. Today with worsening dyspnea, reports increased thick yellow secretions through tracheostomy and hypoxia. Hx of HIV, multinodular goiter, COPD, tracheal compression most likely due to extrinsic compression due to enlarged thyroid s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25. Pt was transferred to ICU do to hypoxemic respiratory insufficiency, placed on Bipap overnight, switch to HFNC 40L/100, and stent migration to carina level that needed close monitoring in the ICU.
Onset: 5 days ago Location: Chest Discomfort with Inspiration, throat pain Duration: Intermittent Characteristics: Sore throat, sore back and chest. Aggravating Factors: While coughing. When Laying Flat Relieving Factors: Respiratory treatments, Sleeping with HOB elevated, Suctioning. Treatment: CT ABD Scan STAT ordered, Surgical team on board, labs CBC, BMP, Aptt, PT/INR, blood cx. Close monitoring in ICU.
|
||
|
Current Medications: Albuterol 180 mcg Inhaler, Mucomyst 200 mg/ml solution 600 mg, Ipratropium-albuterol (Duoneb) 0.5 mg-3 mg Neb Solution, Cefepime 2 G in sodium chloride 0.9 % 100 ml IVPB, Peridex 0.12 % solution 15 ml. Solumedrol 60 mg IV push Insulin regular 100 unit/ml Sliding scale. Cardura 4 mg HS Flomax 0.4 mg QD Pantoprazole 40 mg IV Push QD Cobicistat 150 mg Tab, Darunavir 800 mg tab, Dolutegravir 50 mg tab. Precedex 400 mcg in sodium chloride 0.9 % infusion titrate as per orders. Lexapro 20 tab. Zyprexa 20 mg HS Zolpidem (Ambien) 10 mg Tab HS.
|
||
|
PMH: HIV, multinodular goiter, COPD, DM, BPH, Depression, Tracheostomy.
Medication Intolerances: None
Chronic Illnesses/Major traumas: HIV, COPD, IDDM
Screening Hx/Immunizations Hx: Up to Date, Influenza and Pneumococcal.
Hospitalizations/Surgeries:
s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25 |
||
|
Family History: Father-60 years old died from Lung Cancer. Mother-72 years old died from Heart Attack. |
||
|
Social History:
Patient comes from LTACH. Smoked in the past, denies alcohol or drug us. Non-Ambulatory. Requires frequent repositioning to prevent bedsores. Fall precautions and Aspiration precautions in place. |
||
|
ROS |
||
|
General
AAOx1. Appears fatigued and mild respiratory distress. |
Cardiovascular
· Hemodynamic monitoring and management. · Continue Cardura 4 mg. |
|
|
Skin
Normal, Warm and Dry. Good skin turgor. |
Respiratory
· Strict airway monitoring due to mass and stent migration to carina. · Continue Cefepime for multifocal PNA · HFNC, NRM w/ heliox treatment · Continue nebulizer · Keep FiO2 >92% · Suction PRN |
|
|
Eyes
Denies visual loss, blurred vision, or double vision. Denies history of cataracts or glaucoma. Uses glasses. |
Gastrointestinal
· NPO Status · Gi Px: Protonix
|
|
|
Ears
Denies recent infections, ear pain, or tinnitus. Hard of hearing. |
Genitourinary/Gynecological
No acute issues: Denies urinary urgency, frequency, dysuria, odorous urine, suprapubic pain. · Continue monitoring of renal function, I/O, and electrolytes. Replace PRN. · Maintenance IV Fluids at 50 ml/hr. · CKD (Baseline Cr 1.5) · Continue Flomax to prevent urinary retention. |
|
|
|
|
|
Nose/Mouth/Throat
Denies nasal pain, drainage, congestion, or other sinus issues. Denies throat pain or swelling. |
Musculoskeletal
ROM limited. Bedbound. · PT/OT ordered · OOB to Chair
|
|
|
Breast
Denies discharge, tenderness. No palpable mass during exam. |
Neurological
Sleeping, arousable upon calling. AAOx1 |
|
|
Heme/Lymph/Endo
· Afebrile · Leukocytosis · Continue HART Meds. · Pending OR this week for migrated Stent in the Carina. |
Psychiatric
· AAOx1 · Continue Lexapro 20 QD · Continue Zyprexa 20 mg and Ambien 10 mg HD · Titrate Precedex as ordered. |
|
|
OBJECTIVE |
||
|
Weight 167 lbs BMI 26.30 kg/m |
Temp 98.1 |
BP 107/57 |
|
Height 5’7” |
Pulse 65 |
Resp 20 |
|
PHYSICAL EXAMINATION |
||
|
General Appearance Patients currently sleeping, easy to arouse. Weakness, fatigued. No distress noted. Denies pain or discomfort at the moment. |
||
|
Skin Skin is intact, warm, dry, and adequate color. Normal skin turgor. Capillary refills < 3 seconds.
|
||
|
HEENT Head in normocephalic/atraumatic. Visual field full by confrontation. Conjunctiva pink, sclera white. Pupils 3 mm equally, round react to light and accommodation. EOM intact. No nose discharged noted. Fontal sinuses non-tender to palpation. No bleeding gum noted. Buccal mucosa dry, pink, and intact. Uvula midline, no exudate noted. Tracheostomy noted. No JVD noted. |
||
|
Cardiovascular Currently NSR. No murmurs noted upon auscultation. Denies Chest Pain. |
||
|
Respiratory Diminished breath sounds to auscultation bilaterally. No wheezing or stridor noted. Saturation 99-100 % on HFNC 40 L/100%. |
||
|
Gastrointestinal Abdomen soft, non-distended, round. Bowel sounds present. Last BM reported yesterday.
|
||
|
Breast No lumps noted on palpation. Symmetrical. |
||
|
Genitourinary No inguinal Hernias or CVA tenderness. Urine clear and yellow. Monitor I/O. |
||
|
Musculoskeletal Frequent repositioning. OOB to chair with PT. Weaknesses. Limited ROM. No cyanosis or pedal edema. |
||
|
Neurological AAOx1 to self, disoriented to situation, time, place. Speech clear. Following simple commands. Weakness BL upper and Lower extremities. Denies headache or dizziness. |
||
|
Psychiatric Patient with hx depression and anxiety. Calm and pleasantly confused at the moment. |
||
|
Lab Tests: CBC, BMP, aPtt, PT/INR, Blood cx, Urine Analysis, Sputum Cultures ABG to evaluate hypoxemia and hypercapnia. CD4 count and HIV viral load to assess immune status |
|
|
|
Special Tests: Surgical Consult, CT Chest and Neck w/o contrast, Chest Xray To asses for PNA and stent positioning. |
|
Diagnosis |
|
· Primary Diagnosis- · J96.01 - Acute Respiratory Failure with Hypoxia · Z93.0 Tracheostomy status · R09.02- Hypoxemia · R50.9- Fever, unspecified. · J38.4 – Edema of Larynx
o Differential Diagnoses : Acute COPD exacerbation. Thyroid-Related Airway Compression. Stent related Complications. Infectious Process likely bacterial tracheitis or Pneumonia.
o Plan: Daily CT chest and neck, Chest Xray, and Labs. · Possible emergent Bronchoscopy if stent causes obstruction. · Referrals for Pulmonology for airway management, Surgical Consult for multinodular goiter and removal of stent. ID following, and PT/OT to mobilize patient and prevent skin breakdown. Continue antibiotics, steroids and Nebulizers Tx. Education: NPO status, importance of repositioning |
|
References
|
SOAP NOTE