Unit 10 SOAP note

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 INFORMATION:

S Subjective

HPI:

50-year-old female presents with complaint of a painful bump in the external ear for several days. Patient reports increasing tenderness, swelling, and localized redness. Describes pain as throbbing and rated 6/10. Denies hearing loss, dizziness, fever, or drainage prior to visit. No recent trauma reported.

Patient concerned it may be infected.

Past Medical History:

• Hypothyroidism
• Rheumatoid arthritis
• Fibromyalgia
• Epilepsy
• Asthma

Medications:

[Not fully listed review medication reconciliation]

Allergies: [Not documented]

O Objective

Vital Signs:

[Insert vitals]

General: Alert, no acute distress

HEENT:

• External ear with localized erythematous, fluctuant lesion consistent with abscess
• Tender to palpation
• Mild surrounding edema
• No mastoid tenderness
• Tympanic membrane intact
• No active drainage prior to procedure

Procedure Performed:

Incision and drainage (I&D) of abscess performed under sterile technique. Purulent drainage expressed. Area cleansed and dressed. Patient tolerated procedure well.

A Assessment

1. Staphylococcal skin infection External ear abscess
2. History of hypothyroidism
3. Rheumatoid arthritis
4. Fibromyalgia
5. Epilepsy
6. Asthma

P Plan

Medications:

• Trimethoprim-sulfamethoxazole (Bactrim DS 800/160 mg) 1 tablet PO twice daily x 10 days
• Mupirocin 2% ointment Apply to affected area three times daily

Wound Care:

• Keep area clean and dry
• Warm compresses 34 times daily
• Monitor for increasing redness, swelling, fever, streaking

Education:

• Discussed signs of worsening infection (fever, spreading redness, severe pain)
• Advised to complete full antibiotic course
• Avoid manipulation of area

Follow-Up:

• Return in 23 days for wound recheck
• Sooner if worsening symptoms