PRAC 6541 Assignment: Primary Care of Adolescents and Children

PRAC 6541 Assignment: Primary Care of Adolescents and Children

PRAC 6541 Assignment: Primary Care of Adolescents and Children

Focused SOAP Checklist

SUBJECTIVE:

• Chief Complaint: Did I state briefly in the patient’s own words
• History of present illness: Did I write a paragraph in the order of the 7 attributes & did I put the 7 attributes in a concise list in the chart (OLD CART-if you don’t know it, please look it up)
• Medications: did I list each medication and reason.
• Allergies: Did I include specific reactions to medications, foods, and insects, environmental?
• Past Medical History (PMH): Did I list all the patient Illnesses, hospitalizations? Did I Include childhood illnesses
  

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• Past Surgical History (PSH): Did I list the dates, indications and types of operations?
• OB/GYN History: (if applicable) Obstetric history, menstrual history, methods of contraception and sexual function.
• Personal/Social History: Tobacco use, Alcohol use, Drug use, risky sexual behavior. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits. Pediatrics: school status, parental smoking hx, birth history, school/daycare etc
• Immunizations: Did I include Last Tdap, Flu, pneumonia, etc. Pediatrics- (per pediatric schedule for age) HPV if applicable
• Family History: Did I list for Parents, Grandparents, siblings, children?
• Review of Systems (SUBJECTIVE DATA): Did I include the systems related to my Chief Complaint and chronic conditions? Did I type detailed description? I did NOT use WNL. I was specific in my descriptions (see health assessment textbook). Did I remember this is what the patient says and not what I observed? Did I include the cardiovascular and respiratory system regardless of chief complaint?

Physical Exam: (OBJECTIVE DATA) This is what YOU see/touch/hear/smell

• Did I list the vital signs as the first thing in the objective section? Did I include the BMI for adults? Did I include the percentile for the ht, wt, bp etc for pediatrics?
• Did I examine the systems that are pertinent to the CC, HPI, and History. Did I describe what I observed? Did I never use WNL or normal? Did I describe what I observed during the physical exam?
• Did I include the systems in a list format?
• Did I include cardiovascular and respiratory systems regardless of cc?
• Did I delete the systems I did not review?

ASSESSMENT:

• Did I put my priority diagnosis in bold for EACH CC?
• Did I include at least 3 differentials(DD) after the priority diagnosis for EACH of my CC?
• Did I explain what each DD is, use references to explain and tell how you ruled in or ruled out each DD? (AND does your ROS and PE reflect this?)
• Did I include a reference citation for each diagnosis under the assessment area?
• Are my assessments concise and in a chart format?
• Did I put my differential diagnosis in order by priority?
• Did I provide a detailed rationale for each diagnosis?

Holistic care:

• Did I cover existing diagnoses and whether any changes need to be made?
• Did I include needed preventative care based on my patient’s age and risk factors?

PLAN:

• Did I include a treatment plan?
• Did I address if labs, x-rays, etc. were needed?
• Did I include a pharmacological plan and citation for EBP?
• Did I include non-pharmacological strategies?
• Did I discuss alternative therapies if applicable?
• Did I state when the patient needs a follow-up?
• Did I indication if any referrals or consultations were necessary or not necessary?
• Did I write a rationale based on evidence?
• Health Promotion: Did I address this area? Did I state what the patient/ family need to do to promote their health based on the USPTF for adults or Bright Futures for children? Did I document my citations?
• Disease Prevention: Did I do these based on recommendations from USPTF for adult’s or Bright Futures for children based on the patient’s age? Did I state what needs to be done to detect disease early…fasting lipid profile, mammography, colonoscopy, immunizations, etc? Did I cite the source?

REFLECTION:

• Did I state what I learned from this experience?
• Did I state what I would you do differently or if I would do everything the same and the rationale?
• Did I state if I either agreed or disagreed with my preceptor based on evidence (and cite references for EBP?
• Did I state what I would do if the person was insured versus if the person was not insured? Indicate how this would change your plan.
• Did I state the community resources in my area?

APA

• Do I have a minimum of 3 scholarly journal articles? (NONE OF WHICH ARE PATIENT EDUCATION SITES THAT I GOOGLED)
• Did I use at least 3-4 course resources?
• Do I have the paper in a neat format?
• Did I list my references in APA format?

Developed by Joyce Turner, NP.  Revision 2/22/17 by Nancy Hadley, DNP, APRN, FNP-BC

Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.”

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start every HPI with age, race, and gender (e.g., 34-year-old African American male). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance.

PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.

Soc & Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.

Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx: Prior surgical procedures.

Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx: Concern or issues about safety (personal, home, community, sexual—current and historical).

Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (yes or no), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), and any sexual concerns.

ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. LMP: MM/DD/YYYY.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.

REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Physical exam: From head to toe, include what you see, hear, and feel when conducting your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT:).

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?

Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).

References

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.