{"coupon":"","discount":"","doc_name":"SOAP Note","doc_id":69278,"editorId":"65","email":"branden85@hotmail.com","message":"<p>TEXAS WOMAN&rsquo;S UNIVERSITY<\/p>\r\n<p>COLLEGE OF NURSING<\/p>\r\n<p>NURS 5644 ADVANCED HEALTH ASSESSMENT\/DIFFERENTIAL DIAGNOSIS<\/p>\r\n<p>FOCUSED SOAP EVALUATION CRITERIA<\/p>\r\n<p>Name:_____________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<\/p>\r\n<p>&nbsp;<\/p>\r\n<p>Date:______________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Faculty:__________________<\/p>\r\n<p>&nbsp;<\/p>\r\n<p>0 = incomplete or omitted<\/p>\r\n<p>1 = &lt; 50% of required information is collected and documented<\/p>\r\n<p>2 = 50% of data is present<\/p>\r\n<p>3 = 75% of data is present<\/p>\r\n<p>4 = Thorough and complete with no missing data<\/p>\r\n<p>&nbsp;<\/p>\r\n<p><strong>Patient Identifying Criteria:<\/strong><\/p>\r\n<p>Narrative to include patient&rsquo;s initials, age, race, marital status, education, others accompanying patient, clinic, insurer.<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<\/p>\r\n<table>\r\n<tbody>\r\n<tr>\r\n<td width=\"471\">\r\n<p>S-O-A CONTENT<\/p>\r\n<\/td>\r\n<td width=\"256\">\r\n<p>GRADING SCALE<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"471\">\r\n<p><strong>Subjective (S)<\/strong><\/p>\r\n<p><em>Chief complaint (CC)<\/em> in patient&rsquo;s own words<\/p>\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<td width=\"256\">\r\n<p>&nbsp;<\/p>\r\n<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"471\">\r\n<p><strong><em>History of Present Illness (HPI)<\/em><\/strong><\/p>\r\n<ol>\r\n<li>Onset (sudden or insidious)<\/li>\r\n<li>Location (radiation over time)<\/li>\r\n<li>Duration (how long has it been a problem for patient)<\/li>\r\n<li>Character (burning stabbing, associated factors like nausea, vomiting, diarrhea, rash, etc.)<\/li>\r\n<li>Aggravating factors (food, voiding, defecation, heat cold, motion, environmental)<\/li>\r\n<li>Relieving factors (OTC, voiding, defecation, food, heat cold, motion, environmental)<\/li>\r\n<li>Timing (continuous, intermittent, cyclic)<\/li>\r\n<li>Severity (impact on activities of daily living, pain scale as indicated)<\/li>\r\n<\/ol><\/td>\r\n<td width=\"256\">\r\n<p>&nbsp;<\/p>\r\n<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"471\">\r\n<p><strong><em>Past Medical History <\/em><\/strong><\/p>\r\n<ol>\r\n<li>Medications (prescriptions, OTCs, CAMs)<\/li>\r\n<li>Allergies (medications, food, environmental exposures)<\/li>\r\n<li>Major adult illnesses (physiological, psych)<\/li>\r\n<li>Childhood illnesses<\/li>\r\n<li>Serious accidents\/injuries<\/li>\r\n<li>Surgeries<\/li>\r\n<li>Hospitalizations<\/li>\r\n<li>Blood transfusions<\/li>\r\n<li>OB\/GYN history, (age at menarche, number of pregnancies, deliveries, types of deliveries, STIs)<\/li>\r\n<\/ol><\/td>\r\n<td width=\"256\">\r\n<p>&nbsp;<\/p>\r\n<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"471\">\r\n<p><strong><em>Family History<\/em><\/strong><\/p>\r\n<p>Parents, maternal and paternal grandparents, siblings, &amp; children<\/p>\r\n<\/td>\r\n<td width=\"256\">\r\n<p>&nbsp;<\/p>\r\n<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"471\">\r\n<p><strong><em>Previous Health Care\/Health Promotion<\/em><\/strong><\/p>\r\n<p>Health Maintenance Practices:<\/p>\r\n<ol>\r\n<li>Last Physical Exam&nbsp;&nbsp;<\/li>\r\n<li>Recent Screening tests (Pap, Mammogram, Prostate, Vision, Dental) Provide date and results.<\/li>\r\n<li>Self-screening\/monitoring (skin, vulvar, breast, testicular, etc.)<\/li>\r\n<li>Nutrition<\/li>\r\n<li>Exercise<\/li>\r\n<li>STI protection<\/li>\r\n<li>Personal safety in the home (use of seat belts, sports safety, firearms, medications, toxic substances, smoke detectors)<\/li>\r\n<\/ol><\/td>\r\n<td width=\"256\">\r\n<p>&nbsp;<\/p>\r\n<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"471\">\r\n<p><strong><em>Social History<\/em><\/strong><\/p>\r\n<ol>\r\n<li>Environment&nbsp;&nbsp;&nbsp;&nbsp;<\/li>\r\n<li>Home living conditions\/neighborhood type<\/li>\r\n<li>Occupation<\/li>\r\n<li>Travel\/exposures<\/li>\r\n<li>Economic resources\/concerns<\/li>\r\n<li>Military record<\/li>\r\n<li>Religious or cultural considerations<\/li>\r\n<li>Sexual history<\/li>\r\n<li>Hobbies\/interests<\/li>\r\n<li>Social support network<\/li>\r\n<li>Habits (alcohol, drugs, tobacco, caffeine, illegal substances, (use of vitamins, caffeine, herbs, other dietary supplements)<\/li>\r\n<\/ol><\/td>\r\n<td width=\"256\">\r\n<p>&nbsp;<\/p>\r\n<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"471\">\r\n<p><strong><em>Review of Systems (ROS) systems pertinent for presenting complaint<\/em><\/strong><\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; General<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; Skin<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; Head<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; Eyes<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; Ears<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; Nose<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; Throat and mouth<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; Neck&nbsp;&nbsp; &nbsp; &nbsp;<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; Breasts&nbsp;&nbsp;&nbsp;&nbsp;<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; CV<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; PV<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; Chest\/Lungs&nbsp;&nbsp;<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; GI<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; GU (Female or Male)<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; Musculoskeletal<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; Neuro<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; Psych&nbsp;&nbsp; &nbsp; &nbsp;<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; Endocrine&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;<\/p>\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<td width=\"256\">\r\n<p>&nbsp;<\/p>\r\n<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4<\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<br \/>\r\n<p>&nbsp;<\/p>\r\n<table>\r\n<tbody>\r\n<tr>\r\n<td width=\"471\">\r\n<p><strong>Objective (O)<\/strong><\/p>\r\n<ol>\r\n<li>&nbsp;General Survey<\/li>\r\n<li>&nbsp;Vital signs (pain rating, if indicated)<\/li>\r\n<li>&nbsp;Physical Exam of relevant systems in DETAIL<\/li>\r\n<li>&nbsp;Diagnostic\/lab, imaging results from today&rsquo;s patient encounter as well if pertinent to CC<\/li>\r\n<\/ol><\/td>\r\n<td width=\"256\">\r\n<p>&nbsp;<\/p>\r\n<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"471\">\r\n<p><strong>Assessment (A)<\/strong><\/p>\r\n<p>Differential Diagnoses<\/p>\r\n<ol>\r\n<li>List at least 3 differential diagnoses. Differential diagnosis with the greatest potential for morbidity or mortality should be listed first.<\/li>\r\n<li>Rationale for ruling in\/ruling out for differential diagnoses.<\/li>\r\n<li>Provide references (narrative for rationale should be in APA 6<sup>th<\/sup> Ed. Format)<\/li>\r\n<\/ol><\/td>\r\n<td width=\"256\">\r\n<p>&nbsp;<\/p>\r\n<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4<\/p>\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"471\">\r\n<p><strong>Concluding Diagnosis <\/strong><\/p>\r\n<ol>\r\n<li>Concluding diagnosis fits the patient&rsquo;s H&amp;P (symptoms)<\/li>\r\n<li>Discussed rationale for selecting concluding diagnosis<\/li>\r\n<\/ol>\r\n<p>(narrative for rationale should be in APA 6<sup>th<\/sup> Ed. Format)<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 4. &nbsp; &nbsp; Include ICD 10 code for concluding diagnosis<\/p>\r\n<\/td>\r\n<td width=\"256\">\r\n<p>&nbsp;<\/p>\r\n<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1 &nbsp;&nbsp;&nbsp;2&nbsp;&nbsp; &nbsp; &nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4<\/p>\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"471\">\r\n<p><strong>Health or Injury Risk Factors:<\/strong><\/p>\r\n<p>e.g., unintended pregnancy, falls, domestic violence, STIs, Hep C\/A, diabetes, cancer, injury, CVD<\/p>\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<td width=\"256\">\r\n<p>&nbsp;<\/p>\r\n<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4<\/p>\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"471\">\r\n<p><strong>Plan<\/strong><\/p>\r\n<p>(Individualized and culturally appropriate)<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; Peds &ndash; always include anticipatory guidance.<\/p>\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp; Adults &ndash; Always include health maintenance.<\/p>\r\n<p>Diagnostics - Tests, additional info needed<\/p>\r\n<p>RX &ndash; Pharm, nonpharm (e.g., diet, exercise, complementary care)<\/p>\r\n<p>Education &ndash; Teach\/counsel<\/p>\r\n<p>F\/U&nbsp;&nbsp; and\/or referral-when to RTC<\/p>\r\n<\/td>\r\n<td width=\"256\">\r\n<p>&nbsp;<\/p>\r\n<p>&nbsp;<\/p>\r\n<p>&nbsp;<\/p>\r\n<p>0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp; 3&nbsp;&nbsp;&nbsp;&nbsp; 4<\/p>\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"471\">\r\n<p>Spelling, grammar and APA format for references<\/p>\r\n<p>0= &gt; 8 errors<\/p>\r\n<p>1= 3-7 errors<\/p>\r\n<p>2= &lt; 3 errors<\/p>\r\n<\/td>\r\n<td width=\"256\">\r\n<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 0&nbsp;&nbsp;&nbsp;&nbsp; 1&nbsp;&nbsp; &nbsp; &nbsp; 2&nbsp;&nbsp;&nbsp;&nbsp;<\/p>\r\n<p>&nbsp;<\/p>\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<p>Total Points = ____________ out of possible 50 points<\/p>\r\n<p>Percentage = _____________<\/p>\r\n<p>&nbsp;<\/p>\r\n<p>The total possible score for each SOAP is 50 points. Minimum score for passing is 40 (80%).<\/p>\r\n<p><strong>Comments:<\/strong><\/p>","price_select":"1","temp_doc_name":"upload_57d9de47a58f42.94849164.docx","word_count":"2115","subtotal":57.11,"total_amt":57.11,"firstName":"branden","lastName":"blanton","lastfour":"4863","exp":"0719","address":"708 Bentley Court","city":"Tyler","zip":"75703","state":"Texas","country":"United States","transactionReference":"8648559547"}