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SOAP Note
Ellen C. Turner, 47, Female
- Scenario Description
- Ellen is a 47 y/o AA female G0P0 with a PMH of HTN. She presents to the clinic with a 5 week history of left breast lump. Ellen says it was self-detected as she performs her SBE (self-breast exams) monthly. She waited to cycle again to recheck and the lump persisted. She has no pain, nipple discharge or recent trauma, and her last mammogram was 18 months ago and was normal. She is concerned as her mother went through premature menopause at age 39 and died of breast cancer at age 49. She has high blood pressure, on medication for 1 year now. She admits to being too busy to regularly check her blood pressure but she is adherent to taking her HCTZ 25 mg daily. She takes Levonorgestrel/Ethinyl Estradiol 0.15 mg/0.30 mg daily for the last 15 years when her periods became more irregular.
S: Subjective information. Everything the patient tells you. This includes several areas, including the chief complaint (CC), the history of present illness (HPI), medical history, surgical history, family history, social history, medications, allergies, and other information gathered from the patient. A commonly used mnemonic to explore the core elements of the (HPI) is OLD CARTS, which includes: Onset, Location, Duration, Characteristics, aggravating factors, Relieving factors, Treatments, and Severity.
O: Objective is what you see, hear, feel or smell. Your physical exam, including vital signs.
A: Assessment/your differentials
P: Plan of care including health promotion and disease prevention for the patient related to their age and gender.
If there are any questions, please contact your instructor.
DUE: Should be submitted to the journal Dropbox by end of the unit week, end of day (EOD) Tuesday.
SOAP Note Write Up for VR Patient Ellen C. Turner
This will demonstrate your ability to provide age-appropriate anticipatory guidance, while recognizing the need to refer patients that are outside of the scope of practice of the family nurse practitioner. This will be demonstrated by completing a SOAP note, based on a patient Ellen Turner seen in Unit 6 in the VR platform.
Write-ups
The SOAP note serves several purposes:
- It is an important reference document that provides concise information about a patient’s history and exam findings at the time of patient visit.
- It outlines a plan for addressing the issues which prompted the office visit. This information should be presented logically and prominently features all of the data that’s immediately relevant to the patient’s condition.
- It is a means of communicating information to all providers involved in the care of a particular patient.
- It allows the NP student to demonstrate their ability to accumulate historical and examination-based information, use their medical knowledge, and derive a logical plan of care.
Knowing what to include and what to leave out will largely depend on experience and your understanding of illness and pathophysiology. If, for example, you were unaware that chest pain is commonly associated with coronary artery disease, you would be unlikely to mention other coronary risk factors when writing the history. As you gain experience on SOAP Notes, your write-ups will become increasingly focused. You can accelerate the process by actively seeking feedback about all the SOAP notes you create and reading those written by more experienced practitioners.