Practicum Experience: SOAP Note
After completing this week’s Practicum Experience, You examine a patient with Urinary Tract Infection (UTI) during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:
1). SUBJECTIVE DATA: What details did the patient provide regarding his or her personal and medical history? What the patient tells you but organized by you in logical fashion
a).Chief Complaint (CC): One to three words explaining why patient came to clinic
History of Present Illness (HPI): Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender. (Example: 34-year-old AA male) Must include the 7 attributes of each principal symptom:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
b).Medications: list each one by name with dosage and frequency
c).Allergies: include specific reactions to medications, foods, insects, environmental
e).Past Medical History (PMH): Illnesses, hospitalizations, risky sexual behaviors. Include childhood illnesses
e).Past Surgical History (PSH): Dates, indications and types of operations
f).OB/GYN History: Obstetric history, menstrual history, methods of contraception and sexual function, if the patient is a female.
g).Personal/Social History: Tobacco use, Alcohol use, Drug use. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits
h).Immunizations: Last Time, date and place, Flu, pneumonia, etc.
I).Family History: Parents, Grandparents, siblings, children
J).Review of Systems: Go Head to toe. Cover each system that covers the Chief Complaint, History of Present Illness and History. YOU DO NOT NEED TO DO THEM ALL UNLESS YOU ARE DOING A TOTAL History &Physical. Remember, this is what the patient tells you.
General: any recent weight changes, weakness, fatigue, or fever
Skin: e.g. rashes, lumps, sores, itching, dryness, changes, etc.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular:
Gastrointestinal:
Peripheral vascular:
Urinary:
Genital:
Musculoskeletal:
Psychiatric:
Neurological:
Hematologic:
Endocrine:
2). OBJECTIVE DATA: What observations did you make during the physical assessment? This is what you see, hear, feel when doing your physical exam. Again, you go head to toe and you only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.
Here is where the vital signs go. Include ht. and wt. and BMI.
General: General state of health, posture, motor activity and gait. Dress, grooming, hygiene. Odors of body or breath. Facial expression, manner, affect and reactions to people and things. Level of conscience.
SKIN:
HEENT:
Neck:
Chest/Lungs:
Heart/Peripheral Vascular:
Abdomen:
Genital:
Musculoskeletal:
Neurological:
3).Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why? : Need to list your priority diagnosis (es) first. For each priority diagnosis, list at least 3 differential diagnoses. Support your selection with evidence.
Example: Migraine headache (tension headache, cluster headache, brain tumor)
Hypertension (renal disease, stress, renal artery stenosis)
4).Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies? Treatment plan. Include both pharmacological and non-pharmacological strategies. Include alternative therapies. When do they need to follow-up? Any referrals? Consultations?
a). Health Promotion: What does the patient family need to do to promote their health? Exercise, healthy diet, safety, etc.
Disease Prevention: For the patient’s age, what needs to be done to detect disease early…fasting lipid profile, mammography, colonoscopy, immunizations, etc.
5).Reflection notes: What did you learn from this experience? What would you do differently in a similar patient evaluation? Do you agree with your preceptor based on the evidence?
Readings Resources
• Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2013). Primary care: A collaborative practice (4th ed.). St. Louis, MO: Mosby.
o Part 13, “Evaluation and Management of Genitourinary Disorders” (pp. 732–750)
This part explores the pathophysiology, clinical presentation, and management of Urinary Tract Infection including incontinence. It also provides a differential diagnosis for this disorders.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Mosby. Chapter 18 and 19
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