USC Health & Medical A Male with Shortness of Breath Soap Nursing Assignment Help

Write a soap note using this information and the template below:

73 year old Hispanic male comes into the clinic with complaints of a cough that started 5 days ago, shortness of breath, chills and a temperature of 101.2. He has not taken any medications. 

Problem-Focused SOAP Note Format

Demographic Data

  • Age and gender (must be HIPAA compliant)

Subjective

  • Chief Complaint (CC): A short statement about why they are there
  • History of Present Illness (HPI): Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment
  • Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance
  • Family Hx: any history of CA, DM, HTN, MI, CVA?
  • Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
  • Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)

Objective

  • Vital Signs
  • Physical findings listed by body systems, not paragraph form- Highlight abnormal findings

Assessment (the diagnosis)

  • At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each
  • Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation

Plan

  • Dx Plan (lab, x-ray)
  • Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)
  • Pt. Education, including specific medication teaching points
  • Referral/Follow-up
  • Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due

Reference

  • Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly. 

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