Academic clinical SOAP notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical-thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating evidence-based plans of care.

Develop a hospital follow-up progress SOAP note based on a clinical patient from your practicum setting. In your assessment, provide the following:

  • A one-sentence description of the primary working diagnosis, pending differential diagnoses, and the context or service in which the patient is being seen.
  • A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures. Include how many days the patient has been hospitalized, if applicable.
  • List of at least five systems affected by the working diagnosis. Provide two positive or negative effects that the working diagnosis has on each system.
  • List of at least five systems examined within the past 24 hours. Provide at least two pertinent positive or negative findings relevant to each system examined and include a full set of vital signs.
  • List of all admission diagnostics conducted for this visit or conducted within the past 24 hours.
  • List of all pertinent acute and chronic diagnoses in order of priority using ICD-10. Identify any differential diagnoses being eliminated.
  • Treatment plan that corresponds with the diagnosis. Provide information on admission type, types of diagnostics, any prescribed medications and dosages, and any relevant consults or follow-up procedures needed.
  • Discussion of any relevant ethical, legal, or geriatric-specific considerations.

This assignment uses a template. Please refer to the “Academic Clinical SOAP Note Template.”

Incorporate at least three peer-reviewed articles in the assessment or plan.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite Technical Support Articles is located in Class Resources if you need assistance.

Benchmark Information

This benchmark assignment assesses the following programmatic competencies:

MSN ACNP

7.2: Coordinate evidence-based, patient-centered care across the health care system as a member of the interprofessional and intraprofessional health care team.

ANP-Progress/SOAP Note Template


Reason for follow up:
A one-sentence description of the primary working diagnosis that identifies admit date or hospital day of visit, pending differential diagnoses, and context or service in which the patient is being seen is provided and includes supporting details.


Clinical course summary:
A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is complete with supporting documentation. (This is not the HPI.)


Review of systems:
Review of the symptoms the patient or his/her family explains, organized by system. Five systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are provided with thorough details and support. Refer to the H&P template for ROS options.


Physical exam:
Five systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are provided with thorough details and support. Refer to the H&P template for ROS options.


Laboratory and radiology results:
List pertinent data available when seeing the patient pertinent to the reasons for follow up. Include normal and abnormal results identifying the abnormals.


Assessment: (Provide three references)
Identification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are provided with thorough details and support.

·
Differential diagnoses
: What is pending to be ruled in or ruled out? A differential is only needed if there is a sign/symptom for which you have not identified a diagnosis.

·
Acute and chronic medical conditions:
Include the ICD-10 diagnosis code (look in Lopes Activity Tracker)


Treatment plan: (Provide three references)
A treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is provided with thorough details and support.

What orders are you starting? What medications (include dose and frequency of new meds or changes in dose of existing meds)? What consults? Education topics? Discharge plan?


Geriatric considerations:
Based on the age, please address any differences in the treatment if the patient were younger or older.

References: Use three references listed in APA format.

© 2021. Grand Canyon University. All Rights Reserved.

Running head: ACADEMIC CLINICAL SOAP NOTE 1

Academic Clinical Soap Note

Grand Canyon University

ANP 650

September 25, 2019

ACADEMIC CLINICAL SOAP NOTE

SUBJECTIVE

Chief Complaint:

Patient is in clinic today for second peptide receptor radionuclide treatment (PRRT)

with Lutathera treatment.

Background:

This is a pleasant 47-year-old female with a history of metastatic pancreatic

neuroendocrine tumor. She was initially diagnosed in October 2016 presenting with

pneumonia with an incidental lung nodule noted. Biopsy demonstrated low-grade

neuroendocrine of 1%. She then was noted to have metastatic disease in the right breast

biopsy proven in February 2017. Somatostatin analog therapy was initiated then. When the

patient progressed in September 2017 she was transitioned to Afinitor. A right thyroid nodule

was noted and biopsied in December 2018 with benign findings. That due to Tait scan in

January 2019 showed progression of disease. She was transitioned to Capoten for one cycle

with recurrence of pancreatitis as well as development of splenic vein thrombus in February

2019. She had persistent pancreatitis in March 2019 on CT imaging. After, GI tumor board

review at Stony Brook University Hospital she was found to be metastatic low-grade

neuroendocrine tumor more likely pancreatic origin. Because of persistent abdominal pain

she underwent celiac plexus block in May 2019. She was subsequently referred for peptide

receptor radionuclide therapy/ Lutathera and received first dose on 7/17/2019. She has

recently moved to Florida 3 weeks ago and presents to reestablish for continuation of

Lutathera treatment at Moffitt Cancer Center.

Family History:

Father died of prostate cancer in 1998. Mother had diabetes, heart disease, and

hypertension, she passed in 2010. Patient state she had several uncles that died from cancer,

but she does not recall which cancer they had.

2

ACADEMIC CLINICAL SOAP NOTE

Medication:

 Insulin (Lantus) glargine 20 unit(s), SubQ, DAILY.

 fluticasone nasal (Flonase 50 mcg/inh nasal spray) 2 spray(s), NASAL, DAILY.

 pancrelipase 6000 units oral delayed release capsule, PO, QID.

 Simvastatin 10 mg, 1 tab(s), PO, Bedtime

 Metoprolol 50 mg, 1 tab(s), PO, Daily

 NIFEdipine 30 mg, 1 tab(s), PO, Daily

 Losartan (losartan 100 mg oral tablet) 100 mg, 1 tab(s), PO, AS NEEDED.

 Multivitamin (Multi Vitamin+) PO, DAILY

 Vitamin C lozenge 500 mg, 1 tab(s), PO, Daily

 Multivitamin with iron (Iron 100 Plus) PO, DAILY.

 Multivitamin (Vitamin B Complex oral capsule) 1 c

10

Academic Clinical SOAP Note

MUHAMMAD AFTKHAR

GRAND CANYON UNIVERSITY

5/22/2021

Academic Clinical SOAP Note

Subjective

Chief complaint

The woman presented to the hospital with a chief complaint of shortness of breath (Sharma et al., 2020).

Primary working diagnosis

· Histoplasmosis (B39.9)

Severe shortness of breath with abnormal respiratory rate. Normally, a person has 12-20 breaths in one minute. But she has more than 20 breaths in a minute. This condition is tachypnea.

Pending differential diagnosis

· Bacterial pneumonia (J15.9)

· Immunodeficiency state and Pneumocystis jirovecii pneumonia (B59)

· Carcinoid lung tumors (C7A. 090)

· Tuberculosis (86580)

· Chlamydial pneumonia (138338)

· Mediastinal cysts (39401)

· Recurrent mycoplasma infection (A49.3)

· Pancoast syndrome (C34.1)

· Pneumococcal infection (J18.9)

· Aspergillosis (B44.9)

· Blastomycosis (B40.9)

· Actinomycosis (A42)

History of present illness

A 33-years-old Caucasian woman is admitted to the general ward of the hospital. She was brought to the hospital with a chief complaint of a breathing problem. She notified that she had experienced shortness of breath about six months back. A primary care practitioner diagnosed her with bronchitis at that time and prescribed her bronchodilators along with initiation of empirical antibiotic therapy and oral intake of steroids as well. Moreover, she said this prescription is strictly followed but does nothing to improve my condition. In six months, the condition has become worse than before (Sharma et al., 2020).

Past Medical history:

· Hypertension (99473)

Family history:

· Father has hypertension

· Mother is normal

· Siblings are normal

Past Surgical History:

· Cholecystectomy (47563)

Social History:

The female is working in a bakery shop as a worker. She is married and has three children. His elder child is five years old. She has no hobbies like playing golf. She used to travel to Mexico once a year. She reports cigarette smoking for a long time. But she reduces the consumption of tobacco after the occurrence of symptoms, i.e., from the previous six months. She refuses the use of alcohol or any illegal drugs.

Reproductive History:

She delivered her third baby 15 months ago. She has sexual relations with his husband only and denies any illegal sexual relations with others.

Current Medications

· Anti-hypertensive Drug:

A 10 mg oral dose of Lisinopril

· Budesonide 0.5mg/ 2ml nebulizer 0.25mg, twice daily

Rubic_Print_Format

Course Code Class Code Assignment Title Total Points
ANP-650 ANP-650-XO0103XB Academic Clinical SOAP Note 65.0
Criteria Percentage Excellent (100.00%)
Content 70.0%
Primary or Working Diagnosis 10.0% A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen is provided and includes supporting details.
Brief Clinical Course 10.0% A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is complete with supporting documentation.
Review Of Systems 10.0% Five systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are provided with thorough details and support.
Exam 10.0% Five systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are provided with thorough details and support.
Diagnostics 10.0% Admission diagnostics are provided with thorough details and support.
Impression or Assessment 10.0% Identification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are provided with thorough details and support.
Plan 5.0% A treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is provided with thorough details and support.
Geriatric Specific Care 5.0% A discussion of ethical, legal, or geriatric considerations is provided with thorough details and support.
Organization and Effectiveness 10.0%
Mechanics of Writing (includes spelling, punctuation, grammar, language use) 10.0% Writer is clearly in command of standard, written, academic English.
Format 20.0%
Paper Format (Use of appropriate style for the major and assignment) 10.0% All format elements are correct.
Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style) 10.0% Sources are completely

Academic clinical SOAP notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical-thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating evidence-based plans of care.

Develop a hospital follow-up progress SOAP note based on a clinical patient from your practicum setting. In your assessment, provide the following:

· A one-sentence description of the primary working diagnosis, pending differential diagnoses, and the context or service in which the patient is being seen.

· A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures. Include how many days the patient has been hospitalized, if applicable.

· List of at least five systems affected by the working diagnosis. Provide two positive or negative effects that the working diagnosis has on each system.

· List of at least five systems examined within the past 24 hours. Provide at least two pertinent positive or negative findings relevant to each system examined and include a full set of vital signs.

· List of all admission diagnostics conducted for this visit or conducted within the past 24 hours.

· List of all pertinent acute and chronic diagnoses in order of priority using ICD-10. Identify any differential diagnoses being eliminated.

· Treatment plan that corresponds with the diagnosis. Provide information on admission type, types of diagnostics, any prescribed medications and dosages, and any relevant consults or follow-up procedures needed.

· Discussion of any relevant ethical, legal, or geriatric-specific considerations.

This assignment uses a template. Please refer to the “Academic Clinical SOAP Note Template.”

Incorporate at least three-five peer-reviewed articles in the assessment or plan.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite Technical Support Articles is located in Class Resources if you need assistance.


Benchmark Information

This benchmark assignment assesses the following programmatic competencies:

MSN ACNP

7.2: Coordinate evidence-based, patient-centered care across the health care system as a member of the interprofessional and intraprofessional health care team.