CREATE THE SOP NOTE USING THE GUIDE AND PATIENT INFORMATION

Grading Rubric

Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b) Pertinent positives and negatives must be documented for each relevant system.

c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4) Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.

5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

6) Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

Comments:

Total Score: ____________ Instructor: ___________________

SOAP NOTE: Post-Menopausia bleeding.



STUDENT NAME

MRU


MSN6050 ADVANCE PRACTICE IN PRIMARY CARE- WOMEN’S HEALTH.

PATIENT INFORMATION

Name: Ms. TM

Age: 57 years old

Race: Hispanic

Gender at birth: Female.

Gender identity: Female.

Source: Patient.

Allergies: Penicillin.

Current medications: Lisinopril 10 mg tab, 1tab daily.

Atorvastatin 20 mg tab, 1 tab daily.

Insurance: PPO.

PMH: Denies.

Surgical History: Appendectomy at 13 y/o.

Immunizations: Influenza. December 2020.

Preventive care: Last PAP smear August 2018. Normal.

Mammogram: Normal. BIRADS 0

Exposure: No knows HIV exposure during the last year. No blood transfusions or received other blood components or tissues.

Environmental exposure was unknown to asbestos, radiations or other chemical substances. No exposure to the sunlight during day activities for long periods of time.

Family History: Father deceased CAD.

Mother alive: 85 y/o, HTN.

Social History: Patient is heterosexual, single, and lives with her husband, roommate, and has a daughter 35 y/o. No domestic violence suspected or negligent behaviors. Client denies using drugs she said that she drinks alcohol only socially. Patient denies smoking tobacco or marihuana.

Nutrition history: She reports a healthy diet, low in sugar and salt.

Chief complaint: “I have my period again”

History of present illness: The patient is a Hispanic female, 57 y/o, G1T1P0A0L1, that

comes to the office staying “I have my period again”. She reports that she has watery, bloody

vaginal discharge for 2 weeks. This never happen before. Her last menstrual period was around 8

years ago. The client denied having had vaginal discharge. She is divorced for three years ago

and she did not have sexual activity since that time. The las pap test was in 2018, and the result

comeback negative. She denies history of sexual assault or trauma, also repor

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Grivel J. Hera Gomez APRN, FNP-C

Soap Note # ____ Main Diagnosis ______________

PATIENT INFORMATION

Name:

Age:

Gender at Birth:

Gender Identity:

Source:

Allergies:

Current Medications:

·

PMH:

Immunizations:

Preventive Care:

Surgical History:

Family History:

Social History:

Sexual Orientation:

Nutrition History:


Subjective Data:

Chief Complaint:

Symptom analysis/HPI:

The patient is …


Review of Systems (ROS)

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL:

SKIN:


Objective Data:

VITAL SIGNS:

GENERAL APPREARANCE:

NEUROLOGIC:

HEENT:

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:


ASSESSMENT:

Main Diagnosis

(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.

Differential diagnosis (minimum 3)


PLAN:

Labs and Diagnostic Test to be ordered (if applicable)

· –

· –

Pharmacological treatment:

Non-Pharmacologic treatment:

Education (provide the most relevant ones tailored to your patient)

Follow-ups/Referrals

References (in APA Style)

Examples

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).

ISBN 978-0-8261-3424-0

Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010

(25th ed.). Print (The 5-Minute Consult Series).

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<p><font color=”#FFFFFF” size=”2″>&nbsp; <b>Miami Regional University&nbsp;&nbsp; </b>(Acct #3111)</font></td>
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<td width=”50%”><b><font size=”2″>&nbsp; Case ID #: 2844-20220111-001</b></font><font size=”2″>
&nbsp;&nbsp;(Status:&nbsp;Approved)
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<p align=”right”><b><font size=”2″>Date of Service:
1/11/2022&nbsp;</font></b><font size=”2″></b></font></font></font></td>
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</table>

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<p align=”center”><font color=”#FFFFFF” size=”2″><b>Student Information – Santiesteban Molina, Osmel</b></font></td>
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<p align=”right”><font size=”2″><b>Semester:</b></font></td>
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Spring
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<font size=”2″><b>Course:</b></font></td>
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MSN6050C Advanced Practice Women Health
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<b><font size=”2″>Preceptor: </font></b></td>
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TREJO, RODOLFO
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<b><font size=”2″>Clinical Site</font></b><font size=”2″><b>:</b></font></td>
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Neighborhood Family Doctor.Atlantis
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<b><font size=”2″>
Setting Type</font></b><font size=”2″&g