This post includes Soap Note Assessment and Plan with three examples and guidelines for each section.
SOAP NOTE ASSESSMENT
In the SOAP Note Assessment section, List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines (include ICD guidelines where applicable). Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.
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.
Here are three examples of the SOAP NOTE ASSESSMENT section
Soap Note Assessment and Plan Example 1:
- Otitis externa (Confirmed)
- Associated with recent water exposure. The skin of the outer ear becomes erythematous, swollen, tender, and warm, leading to debris and discharge accumulation. Pain is worse when an otoscope is inserted because sensitivity is on the outer ear. Narrow external auditory canal with purulent discharge (Wiegand et al., 2019). PT meets this diagnosis criteria.
- Otitis media with perforation (Refuted)
- Clear discharge or bloody followed by relief of pain, with an inflamed tympanic membrane with perforation in the middle ear. Associated with ear pain, fever, difficulty hearing, irritability, and lethargy can also accompany this diagnosis. Inflammation in external part of the ear canal thus refuting this diagnosis (Pontefract et al., 2019).
- Eustachian catarrh (Refuted)
- Occurs in the middle ear, and results after an upper respiratory infection (Vasudevan & David, 2016). Patient has a no recent upper respiratory tract infection. Refuted
- Ramsay Hunt syndrome (Refuted)
- Complication of shingles. May present with symptoms of otitis externa, yet has evidence of vesicular eruptions within 2 days of first onset of pain. Pt has no history of shingles, Refuted (Musso & Crews, 2016).
- Contact dermatitis (Refuted)
- Allergic reaction to materials (e.g., metals, soaps, plastics) in contact with the skin/epithelium; itching is predominant (Schaefer, & Baugh, 2012). Pt has no piercing or known allergic reactions, refuted.
Soap Note Assessment and Plan Example 2:
- Herpes Zoster Virus (ICD-9: 053). Rash, pain and eruption of grouped vesicles in the same dermatome and fellow a segment of the body suggests herpes zoster virus. The symptoms described by ABC suggests Herpes Zoster Virus (Dains, Baumann, & Scheibel, 2019)
- Herpes Simplex Virus (ICD-9: 054). Prodrome, which can include symptoms, such as fever, malaise, loss of appetite, and localized pain and/or burning at the site the lesions will occur. Tingling and burning without lesions, to recurrent genital ulcerations. Typical widespread lesions clustered together and predilection for lips and genitalia (Dains, Baumann, & Scheibel, 2019). The rash ABC exhibits is not in the area and is on the same dermatome and is likely to be HSV (Kennedy, & Gershon, 2018).
- Contact Dermatitis (ICD-9: 692). Localized burning, stinging, itching, blistering, redness, and swelling at the area of contact with the allergen or irritant. ABC was not exposed to an allergen or environmental irritant and does not describe the rash as pruritic (Ball et al., 2019).
ASSESSMENT: Herpes Zoster Virus (ICD-9: 053).
Soap Note Assessment and Plan Example 3
- Hypertension Stage 3 or hypertensive crisis (Confirmed) With a BP of This in and of itself indicates a hypertensive crisis (Pierin et al, 2019). It calls for immediate attention by a physician and therefore the patient has to be admitted. A diastolic value of 107 mmHg is better than the systolic value meaning the physician could classify it has hypertension Stage 2 but since the readings are different (one better and one worse the classification is correct to the one considered worse.
- Hypertensive emergency (Refuted) unlike hypertensive urgency which has no associated target organ damage, the patient does not exhibit neurologic, aortic, cardiac, renal, and hematologic damage.
- Secondary hypertension due to another underlying medical condition or drug abuse(Refuted) the patient does not report to have any chronic condition other that spinal stenosis that was diagnosed 6 six years ago. It is hypertension that causes chronic neck pain like the one of spondylosis. Neither does the patient report of having any drug or substance issues.
Therefore the patient cannot take part in the study as his assessment points towards Chronic, unregulated hypertension is diagnosed: specifically hypertension urgency.
SOAP NOTE PLAN SECTION
This section includes the treatment plan for the patient taking into consideration the diagnostic tests, subjective, objective, and assessments of the patient.
Below is a breakdown of what you’ll require for the SOAP Note Plan section
Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.
Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.
Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.
Here are three examples of the SOAP Note Plan Section
Hypertension urgency. Promptly admit the patient for urgent hospital treatment and [pharmacologically manage the hypertension crisis. The physician further determines the type of hypertension crisis and determines that it is hypertensive urgency since there is no end-organ damage (Alley & Schick, 2019). Most importantly, one should remember that if a hypertension crisis is not sufficiently treated aggressively, it can progress to hypertensive urgency where there is a risk of death,
A more specific and comprehensive cardiac assessment will ensue that comprises of a physical exam, taking the blood pressure of each arm, listening to heart and lung sounds, renal arteries, neurological exam, and a funduscopic assessment (Somand, 2020). These are followed by a comprehensive laboratory checkup and should the patient be found to have unbalanced pulses in the palms imaging studies will be required. The patient will also require oral and intravenous medications like diuretics and antihypertensive (for example hydralaxzine, nitrates, and alpha-beta blockers amongst others) to lower and maintain the patients’ blood pressure
Research studies had demonstrated the efficacy of patient education in helping hypertensive patient to contain and maintain their blood pressure at comparatively lower levels. The patient needs to educate on medications used to treat and manage HTN and the need to adhere to the dosage without skipping the prescribed medication. The patient is also made aware of how to self-monitor their BP and self-care at home. Non-pharmacological interventions like regular exercises, taking an HTN friendly diet, and cessation of smoking are some of the lifestyle modifications the patient has to comply with for a healthy and quality life. Sticking to the recommended diet and regular exercise will also have the benefit of checking unnecessary weight gain (Somand, 2020).
Once, the clinician is done with the patient, a referral can be made so that the patient can have a complete assessment conducted a consultant physician/ specialist like a cardiologist for close monitoring of the BP and medication efficacy as well as the levels of serum creatinine and potassium at least twice a year.
Soap Note Assessment and Plan Example 2:
Further diagnostic testing: No further diagnostic test is needed
- Continue with Metformin 250 mg PO BID and Lisinopril 10 mg PO QD for his T2DM and HTN.
- Aripiprazole 30 mg PO BID x14 days: Aripiprazole is an antipsychotic drug that affects multiple receptors, acting as a partial agonist at dopamine and serotonin 1A receptors, and an antagonist at serotonin 2A, α1 adrenergic, and other receptors. The medication has been found effective in calming dementia symptoms (Karlsson et al., 2017).
- Administer Galantamine 4mg PO Q8 hrs x10 days: The medication works by restoring the balance of neurotransmitters in the brain. It has been effective in enhancing memory and the ability to carry out daily functions, besides treating mild to moderate confusion (Koola & Parsaik, 2018).
Educate patient to:
- Ensure compliance to the treatment regimen to achieve positive patient outcomes.
- To increase the regularity of exercise to promote sleep
- Ensure intake of a balanced diet with a variety of foods, including fruits, vegetables, low-fat dairy products, whole grains, and lean proteins to promote healing
- Limit foods with high cholesterol and saturated fats to enhance his health Referrals: Refer the patient for one rehabilitation to ensure that dementia symptoms are addressed. If symptoms do not improve after 7 days of treatment, refer the patient to a geriatrician for additional evaluation.
Follow-up: F/u set in 7 days
Soap Note Assessment and Plan Example 3:
The goals of therapeutic intervention target the resolution of the symptoms and eventual remission while simultaneously minimizing the side effects of the prescribed medicines. Likewise, nonpharmacological interventions should be included through patient education on stress management and adherence to medication (Koutsouleris et al, 2015).
Aripiprazole 10mg QAM to be titrated upwards daily by 1-2mg each day The maintained drug dosage per PUI is 20 mg/day ( Di Sciascio & Riva,2015). The provider needs to review the onset of the medications’ effect as efficacy is not observable for several weeks meaning the patient should be encouraged to continue taking the medication despite its seeming ineffectiveness as this is expected to be temporary. It is important to note that low initial doses and slow titration help to minimize the risk of developing akathisia.
Risk for harm to others is deemed low, the risk for suicide in the current setting low, as do risk for self-harm or self-mutilation. The medications included in the treatment plan were duly discussed, and informed consent was given. The patient may require hospitalization for ongoing psychiatric evaluation and medication adjustment. The other reasons for her admission to a hospital at the hospital are the unstable clinical manifestation of not eating, being too weak to walk, and psychotic delusions.
You are required to include at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differential diagnoses. Be sure to use correct APA 7th edition formatting.
Takeaways ON THE Soap Note Assessment and Plan
SOAP Notes are should follow a set structure. Check whether your instructor has included a template for you to use. Otherwise, you can use our guidelines. However, if you don’t have sufficient time, make use of our nursing writers.
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