Category: uncategorised

Directions: Students may use this general SOAP note template or their own. Save a copy to your device to alter the document. Use APA when called for by the rubric or assignment prompt. The APA title page will be the first page, and the template will start on the second page. End with your APA formatted references. Keep in mind this template is structured for an average, problem-focused visit. This template will not be adequate for some special populations and situations (newborns/pregnancy visits/child wellness, etc.). Students need to use good clinical judgment and make additional headings and sections when needed and remove others as applies.

Consider viewing the EMS documentation guidelines from the US Department of Health and Human Services/CMS:

Delete all text in red – these are instructions and not part of the SOAP document.

Student Name and clinical course: (If no title page):______________________

ID:

Clients Initials*:_______Age_____ Race__________Gender____________Date of Birth___________

Insurance _______________ Marital Status_____________

*It is recommended to include false initials and use Jan 1, XXXX (correct year) to protect client confidentiality. Include brief statement on whether the patient came to the clinic alone or accompanied, and if so by whom, and whether they are a reliable historian.

Subjective:

CC: A few words, a sentence or less. Indicate who provided information about the symptoms. Example: Patient reported that Ive had a cough and sore throat for 2 days

HPI:

In paragraph format, including at the minimum OLDCARTS. Please start with demographics: AA, a 29 y.o. Asian female presents to the clinic alone with complaint of _____________.

Onset, Location, Duration, Characteristics/context, Aggravating factors or Associated symptoms, Relieving Factors, Treatment, and Timing, Severity. Include any pertinent positives or negatives.

Medications: include name, dose, frequency, and route. Include PRN medications and how often they are taken.

Past Medical History:

Medical problem list: details on past and present illnesses, be careful not to blindly copy from prior clinical notes

Preventative care: (if applicable to the case – Paps, mammography, colonoscopy, dates of last visits, etc.)

Surgeries: past surgeries and rough dates when possible

Hospitalizations: past hospitalizations with reason for admit, duration of stay, and rough dates

LMP, pregnancy status, menopause, etc. for women

Allergies:

Food, drug, environmental: list medications and food allergies, specify type of reaction

Family History: go back 2 generation indicate if alive, deceased, or unknown. details on family members, their age, and illnesses/conditions.

Social History:

-Sexual history and contraception/protection (as applies to the case)

-Chemical history (tobacco/alcohol/drugs) (ask every pt about tobacco use)

Other: -Other social history as applicable to each case (diet/exercise, spirituality, school/work, living arrangements, developmental history, birth history, breastfeeding, ADLs, advanced directives, etc. Exercise your critical thinking here – what is pertinent and necessary for safe and holistic care)

ROS (write out by system): Comprehensive (>10) ROS systems for wellness exams or complex cases only. Do not include diagnoses – those belong in PMH. Include only subjective data which patient reports or denies. Do not include any objective data which should go under physical examination. The below categories are per CMS guidelines.

Constitutional:

Eyes:

Ears/Nose/Mouth/Throat:

Cardiovascular:

Pulmonary:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Integumentary & breast:

Neurological:

Psychiatric:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

Objective

Vital Signs: HR BP Temp RR SpO2 Pain

Height Weight BMI (be sure to include percentiles for peds)

Labs, radiology or other pertinent studies: be sure to include the date of labs – might be POC tests from today

Physical Exam (write out by system):

Start with a General survey:

Skin:

HEENT (Head, Eyes, Ears, Nose, Throat):

Neck:

Cardiovascular (Heart):

Respiratory (Lungs):

Abdomen:

Back:

Rectal:

Extremities:

Musculoskeletal:

Neurologic:

Psychiatric:

Pelvic:

Breast:

Genitourinary (G/U):

Assessment

(you will often have more than one diagnosis/problem, but do the differential on the main problem, Support diagnoses with evidence-based references.)

Differentials (with a brief rationale for each):

1.

2.

3.

Diagnosis (may have more than one, include ICD-10 if rubric or as your instructor specifies)

Plan (4 pronged plan for each problem on the problem list, Support plans with national guidelines or evidence-based references.)

Diagnostics:

Treatment:

Education

Follow Up:

Reference

Assignment Overview

You will create a professional PowerPoint presentation on a selected pathophysiology topic. The purpose of this assignment is to deepen your understanding of advanced pathophysiologic mechanisms and to apply that knowledge to clinical practice as an MSN-prepared nurse. By completing this assignment, you will not only build deeper expertise in your chosen topic, but you will also contribute to the collective learning of the class. At the end of this assignment, all student presentations will be available in the discussion board and can be used as a partial review resource for the midterm exam.

Topic Selection

• Chronic Kidney Disease

Criteria for Pathophysiology PPT Assignment

1. Introduction & Background

• Define the disease or disorder.
• Brief epidemiology (prevalence, populations most affected, morbidity/mortality).
• Relevance to advanced nursing practice.

1. Normal Physiology Review

• Concise overview of the normal organ/system function that is disrupted.
• Focus on the specific pathways/cellular mechanisms relevant to the disease.

1. Pathophysiology

• Cellular and molecular mechanisms of disease.
• Key pathologic changes (biochemical, structural, functional).
• Links between genetic, environmental, and physiologic contributors.
• Disease progression (stages, acute vs chronic changes if applicable).

1. Clinical Manifestations

• Signs and symptoms explained by linking them back to the underlying pathophysiology.
• Differentiate early vs late manifestations, typical vs atypical presentations.

1. Diagnostics

• Lab values and imaging findings explained through their pathophysiologic basis.
• Sensitivity/specificity if relevant.
• Include how findings confirm or rule out the disease.

1. Complications & Sequelae

• How progression leads to system-wide effects.
• Long-term organ damage, secondary syndromes.

1. Therapeutic Implications

• Pathophysiology-guided treatment (how mechanisms influence pharmacology, procedures, or other therapies).
• Rationale for specific interventions.

1. Emerging Research / Future Directions

• New molecular insights, precision medicine approaches, or therapies in development.
• Current controversies or gaps in understanding.

1. Summary & Clinical Relevance

• Key takeaways for APRN practice.
• Integration of pathophysiology into assessment and management.

1. References

• Three to five peer-reviewed scholarly sources (within 5 years preferred unless landmark studies).
• Remember in-text citations for every slide as appropriate.
• Proper current APA formatting.

Presentation Requirements

• Slide Design
• Use clear, high-quality photos/illustrations (diagrams of anatomy, pathways, disease progression).
• Use consistent font, size, and color scheme.
• Incorporate figures, charts, or tables where appropriate to visualize complex mechanisms.
• Avoid slides that are overly wordy as your lecture notes should fill in the gaps.
• Speaker Notes
• Provide detailed explanations in the notes section (as if you were delivering the lecture).
• Go beyond whats on the slide, notes should expand and clarify, not repeat.
• Please do not add narration to your slides. This is not part of the grading expectation for this assignment.
• Technical Expectations
• Length: 1520 content slides (excluding title and references).
• File format: PowerPoint (.pptx).
• References: final slide(s) in current APA format.

• Length: A minimum of 150 words per post, not including references
• Citations: At least one high-level scholarly reference in APA per post from within the last 5 years
• Respond to each post separately

post 1

An essential factor in the campaign’s success was its strategic employment of personal narratives and visual storytelling. The campaign, by showcasing firsthand narratives from nurses who encountered violence, effectively resonated with the audience and underscored the pressing necessity for reform. Furthermore, ANA partnered with various stakeholders, such as hospitals and policymakers, to enhance their advocacy, thereby establishing a more cohesive and credible front. This collective involvement heightened national awareness regarding legislation such as the Workplace Violence Prevention for Health Care and Social Service Workers Act, which received bipartisan endorsement in Congress (Powell et al., 2021).

post 2

The Emergency Nurses Association (ENA) uses media to promote health policy changes by focusing on raising public and policymaker awareness and mobilizing its members to advocate for specific legislative and regulatory issues. Campaign issues include ED violence, the opioid crisis, mental health issues, firearm safety, raising federal funding, and promoting initiatives for research on healthy work environments. They provide publications, online resources, and social media to influence facility-level policies and raise awareness among stakeholders (ENA, 2025).