NSG 550 Clinical Soap Note
· Hints for the clinical note
· Start early. There is a week where no weekly post is due in week 7. If that fits in your schedule, you might do your clinical note that week.
· Directions: Go to Content, then Resource, then find Clinical Note Guidelines.
· The directions direct you to have a cover page, a reference page, and 3 pages of content. The outline directs you of what to cover.
· Who can be your patient? Someone who is verbal and can give you a history. It could be, but does not have to be a patient. It could be a willing family member or friend. If it is a patient, be sure to get consent explaining this as a school project.
· Please do a full history and review of systems on your ‘patient.’
· The physical exam should include all non-invasive areas. Depending on the reason for visit, you may or may not complete a breast exam and genital exam.
· Note that the assessment sections and treatment sections are 35% of the paper grade. In the assessment section list your suspected diagnosis and differentials. Have rationale for each of them. In the treatment section (as in your weekly cases) add rationale, expected findings, and teaching for your diagnostics and treatments.
Each student will complete a clinical note utilizing the framework of a comprehensive health history and physical examination. The written assignment is documentation of the findings and should demonstrate application of course content and follow the criteria provided below. This should be in a charting format and no longer than 3 pages, excluding a title and reference page. Five points will be deducted for assignments longer than the stated criteria.
APA not required so single spacing is allowed. Mastering succinctness of communication, both written and verbal of clinical reasoning, is critical to the process of becoming a nurse practitioner.
Content Grade Percentage Choose a patient to perform the H and P; this person could be a family member or patient from your clinical practice. Only use initials when identifying the patient. 5% Chief Complaint and History of Present Illness 5% Past Medical and Surgical History 5% Medications and Allergies 5 % Family History 5% Social History 5% Review of Systems (include only subjective symptoms obtained from the health history –what did the patient say?) 15% Physical Examination (include only objective findings determined by the physical examination you completed). 15% Assessment and Plan (You can make one section with the Assessment/Plan or you can keep them as separate sections). Provide all possible diagnoses based upon clinical decision making listing the one with the highest probability first. Provide comprehensive treatment plan and communicate clinical reasoning; utilize theory from NSG500, 550, 530, and 533. Provide clinical support/citations.35% Provides references of peer reviewed, scholarly citations 5% Total 100% Criteria for this written assignment can be found on the next page below.
History—Subjective Data ID Age, gender, DOB CC Reason for seeking care-patient’s own words HPI O-onset L-location D-duration C-character A-aggravating/associated factors R-relieving factors T-temporal factors S-severity Medications, treatments PMH/PSH General health, surgeries, hospitalizations, illnesses, immunizations, medications, allergies, blood transfusions, emotional status/psychiatric history PERSONAL HISTORY Cultural background, marital status, occupation, economic resources, environment HEALTH HABITS Tobacco, alcohol, illicit drugs, lifestyle, diet, exercise, exposure to toxins HEALTH MAINTENANCE Last PE; diagnostic tests (date, result, follow-up); self-exams (breast, genital, testicular); last Pap smear, mammogram FAMILY HISTORY (Parents, siblings, children) Cancer, DM, hypertension, heart disease, stroke REVIEW OF SYSTEMS GENERAL Fever, chills, malaise, fatigue/energy, night sweats, desired weight DIET Appetite, restrictions, vitamins, supplements SKIN, HAIR, NAILS Rash, eruptions, itching, pigment changes HEAD AND NECK Headaches, dizziness, head injuries, loss of consciousness EYES Blurring, double vision, visual changes, glasses, trauma, eye diseases EARS Hearing loss, pain, discharge, vertigo, tinnitus NOSE Congestion, nosebleeds, postnasal drip
3 THROAT AND MOUTH Hoarseness, sore throat, bleeding gums, ulcers, tooth problems GASTROINTESTINAL Indigestion, heartburn, vomiting, bowel regularity/changes LYMPH Tenderness, enlargement ENDOCRINE Heat/cold intolerance, weight change, polydipsia, polyuria, hair changes, increased hat, glove, or shoe size FEMALE LMP, age at menarche, gravity, parity, menses (onset, regularity, duration, symptoms), sexual life (number of partners, satisfaction), contraception, menopause (age, symptoms) MALE Puberty onset, erections, testicular pain, libido, infertility BREASTS Pain, tenderness, lumps, discharge CHEST AND LUNGS Cough, sputum, shortness of breath, dyspnea on exertion, night sweats, exposure to TB CARDIOVASCULAR Chest pain, palpitations, number of pillows, edema, claudication, exercise tolerance HEMATOLOGY Anemia, easy bruising GENITOURINARY Dysuria, flank pain, urgency, frequency, nocturia, hematuria, dribbling MUSCULOSKELETAL Joint pain, heat swelling NEUROLOGIC Fainting, weakness, loss of coordination MENTAL STATUS Concentration, sleeping, eating, socialization, mood changes, suicidal thoughts Physical Examination—Objective Data VS TPR, BP, Ht, Wt, BMI, Pulse Ox GENERAL APPEARANCE Age, race, gender, posture and gait MENTAL STATUS Consciousness, cognitive ability, memory, emotional stability, thought content, speech quality SKIN Color, integrity, hygiene, turgor, hydration, edema, lesions, hair distribution and texture, nail texture, nail base angle HEAD Scalp, temporal arteries, deformities NECK
4 Trachea (position, tug), range of motion (ROM), carotid bruit, jugular venous distention (JVD), thyroid, lymph (head and neck) EYES Pupils (PERRLA), eyelids, conjunctivae, sclerae, EOMs (CN III, IV, VI), light reflex, visual fields, funduscopy (CN II), acuity (CN II), nystagmus EARS Deformities, lesions, discharge, otoscopy (canal, TM), hearing (Rinne, Weber, CN VIII) NOSE Mucosa, septum, turbinates, discharge, sinus area swelling or tenderness MOUTH AND THROAT Lips/teeth/gums, tongue (CN XII), mucosa, palates, tonsils, exudate, uvula, gag reflex (CN IX, X) CHEST/LUNGS Shape, movement, respirations (rate, rhythm), expansion, accessory muscles, tactile fremitus, crepitus, percussion tone, excursion, auscultation (clear, wheeze, crackles, rhonchi, rubs) BREASTS Contour, symmetry, nipples, areolae, discharge, lumps/masses, lymph (axillary, supraclavicular, and infraclavicular) HEART PMI, lifts, thrills, rate, rhythm, S1, S2, splitting, gallops, rubs, murmurs, snaps BLOOD VESSELS Cyanosis, clubbing, edema, peripheral pulses, skin, nails ABDOMEN Contour, symmetry, skin, bowel sounds, bruits, hum, liver span, liver border, tenderness, masses, spleen, kidneys, aortic pulsation, reflexes, percussion tone, costovertebral angle (CVA) tenderness, femoral pulses, lymph (inguinal) MALE GENITALIA Pubic hair, glans, penis, testis, scrotum, epididymis, urethral discharge, hernias FEMALE GENITALIA External lesions or discharge, Bartholin and Skene glands, urethra, vaginal walls, cervix (position, lesions, cervical motion tenderness), uterus, adnexa RECTUM/PROSTATE Sacrococcygeal and perineal areas, anus, sphincter tone, rectal walls, masses, fecal occult blood test (FOBT) Male: Prostate Female: Rectovaginal septum, uterus MUSCULOSKELETAL Posture, alignment, symmetry, joint heat/swelling/color, muscle tone, ROM, strength NEUROLOGIC CN II-XII, rapid alternating movements, finger-to-nose, sensation, vibration, stereognosis, motor system, gait, Romberg, deep tendon reflexes (DTRs), superficial reflexes CRANIAL NERVES I: Smell II: Visual acuity, visual fields, funduscopy III, IV, VI: Eyelid opening EOMs: IV up and out, VI lateral, III all others
5 V: Corneal reflex, facial sensation (3 areas), jaw opening, bite strength VII: Eyebrow raise, eyelid close, smile, taste VIII: Rinne, Weber IX, X: Gag reflex, palate elevation, phonation XI: Lateral head rotation, neck flexion, shoulder shrug XII: Tongue protrusion, lateral deviation strength Assessment Diagnosis(es)-clinical reasoning Plan Treatment; rationale