NURS 7446/NURS 7556

AU/AUM SON Guidelines for SOAP Notes

Fall 2014

Label each section of the SOAP note

o (each body part and system)
Do not use unnecessary words or complete sentences
Use Standard/Universally accepted abbreviations
Search for and correct all spelling errors prior to submission

S: SUBJECTIVE DATA: (information the patient/caregiver tells you)

Introduction of the patient:
Name: 0303fr
Age: 71
Race: Caucasian
Gender: Male
Marital Status: Married
Historian: pt and daughter who is current primary care taker
Chief Complaint (CC): 4 week follow-up (including protime and
coumadin management)
Pt presents for a 4-week follow-up for check of PT / INR and
adjustment of coumadin dosing as needed.
Daughter of the patient reports she has just now moved in with
her father to take care of him better and that he is not doing
well on diabetic medication, diet, and general overall care of
himself. She reports that he is not eating much food and never
drinks any water. She states this morning he had cookies for
breakfast. She also states he eats at erratic times he eats
dinner sometimes at 6 and then sometimes at 9pm. He has
currently lost 7 pounds in the last 4 weeks but family thinks it
because he is not taking care of his diabetes. Pt is the father of a
mentally handicapped young adult and states since his wife has
been sick he has had to take care of his son and so he has not
had time to take care of himself. Pt also reports those new flex
pens are hard to push sometimes, I dont think I am getting all
my medication. Daughter reports patient has not had diabetes
counseling in the past.
History of present illness (HPI):

A chronological description of the development of the patient's

chief complaint from the first symptom or from the previous
encounter to the present.
Include ALL of these seven variables as it related to the CC/HPI
o Location: weight loss fatigue, general
o Quality: difficulty performing ADL, sugars reported to be in
400s at home. CBG 305 today
o Severity: sugars all over the place diet erratic
o timing : most difficulty is eating breakfast and dinner and
taking insulin
o setting: at home (daughter recently moved back to help)
o alleviating and aggravating factors: alleviating (daughter
and her husband helping to administer shots) aggravating
(difficulty with taking care of himself and his son with wife
being sick as well.
o associated signs and symptoms: blood sugars variable,
neuropathic pain related to disease, changes in energy
level (new fatigue)
Or an update on health status since the last patient encounter if
this is a follow-up visit for a previous acute or chronic visit.
o As stated above this is a follow-up with newer symptoms,
family better able to explain patients long history of
compliance problems.

Past Medical History (PMH):

Update and list current medications (include name, dose,
frequency, and how long the patient has been on this
medication).
o Did the current medication replace a previous medication
prescribed to treat the same problem? If so, note why the
change.
o Note any problems with these medications (i.e. side
effects, price, patient understanding or compliance
issues)
o 1. Crestor 40mg PO QHS
o 2. Lasix 40mg PO once daily, increase to twice daily with
swelling
o 3. Nitro-Stat 0.4mg SUBL PRN chest pain x3 q5min
o 4. NovoLOG MIX 70/30 FlexPen 70/30 35units with meals
o 5. Omeprazole 40mg PO Qday
o 6. Toprol XL 50mg BID (replaced Lisinopril due to
hyperkalemia) K+ 5.9 Resolved
o 7. Ventolin HFA 90mcg (108mcg) 2 puffs Q4hrs PRN has
not been using lately (lack of acute respiratory distress
o 8. Coumadin 2.5mg QDay, except 5mg Fri

Allergies with patient response to the medication or other

allergen (latex, enviornmental).
o 1. Actos : Diarrhea
o 2. Avandia: unknown
o 3. Losartan: intolerance (unknown)
o 4. Niacin: Hives / Rash
o 5. Percocet: Palpitations
Prior illnesses and injuries with dates of onset/occurrence,
previous or current treatments, and current (outcome) status of
these illnesses and/or injuries.
o Atrial Fibrillation.: Currently followed by cardiology. Today
in NSR per EKG taking coumadin for prevention, also
taking Toprol XL for rate control
o Chronic Interstitial Lung Disease: Taking Ventolin HFA as
needed (states he has not had to have any medications in
the last week or two. Pt lung sounds are clear at this time.
Pt denies productive cough
o Congestive Heart Failure Systolic: Currently having no
shortness of breath or edema, takes lasix as needed when
having lower extremity edema, pt states he takes lasix
once or twice a week.
o Coronary Artery Disease: currently followed by cardiology
3 vessel bypass in 1998. Taking Crestor for management
of hyperlipidemia to reduce risk.
o Diabetes Mellitus type 2 w/ neuropathy: Out of control at
this time, pt and family denies history of diabetes
training, current CBG is 305, A1C 9.0% with previous A1C
4 months prior at 10.8,. pt reporting difficulty with insulin
pen, but states he is starting to understand it.
o Gastritis: Managed with omeprazole 40mg PO pt last EGD
2010 showing gastritis, placed on PPI and now having no
issues. Next EGD scheduled due 2015.
o Gerd: currently managed with omeprazole 40mg PO ,
states I take it every day so I dont burn. Last EGD at
2010 showing gastritis without ulceration.
o Hyperlipidemia: Controlled at this time as evidenced by
normal lipid panels x last 3 with Crestor 40mg PO QDay.
o Sleep Apnea Obstructive: Controlled with CPAP, pt last
mask change 4 months prior and doing well. Pt reports he
wears his mask every night. States only difficulty is when
he has sinus stuffiness
Date and name of previous operations
o Knee replacement right sided 1996
o Knee replacement left sided 1997
o CABG bypass graft x 3 1998

o Right Cataract extraction with lens placement 2006

Description of previous hospitalizations, treatments and
outcomes.
o 1973: Appendicitis: Appendectomy
o 1989: Pneumonia: IV abx and IV steroids: DX of interstitial
lung disease: pt quit smoking after this diagnosis
o 1996 knee replacement
o 1997 knee replacement
o 1998 CABG extensive stay in hospital for medication
management and had cardiac rehab after CHF
exacerbation
o 2003 CHF exacerbation with shortness of breath, dx of afib placed on atenolol and coumadin
Documentation of age-appropriate immunization (vaccines) and
compliance with health promotion and health maintenance
guidelines as identified by the CDC and NIH (i.e. colonoscopy,
pap smears, mammograms, etc).
o Colonoscopy UTD 2012
o TDaP up to date 2010
o Zostavax given 2012
o PPSV 23 given 2009
o PCV13 to receive today
o Influenza given yearly and UTD
o PSA checked yearly and normal

Family History (FH):

Update significant medical information about the patient's family
(parents, siblings, and children).
o Sister: unknown age had tongue cancer with removal died
at age 53
o Mother: unknown age heart disease, unknown age CVA
died at 84
o Father died 76 Heart Disease, unknown age CVA
o Son: Mental Retardation
o Daughter: 33 no known health problems
o Daughter 41 Smoker, DM
Provide current age of parents, siblings, children; years with
disease; or age at death and cause of death.
Include specific diseases related to problems identified in CC,
HPI or ROS.
Social History (SH):
An age-appropriate review of significant activities that may
include information such as marital status, living arrangements,

occupation, history of use of drugs, alcohol or tobacco, extent of

education and sexual history.
o Marital Status: Married
o Living arrangements: Lives with wife, son (mental
retardation), daughter has moved closer and stays over
some nights and checks in most days
o Occupation: Retired disabled, blue collar worker,
mechanic
o Negative Drug Use, No consumption of alcohol
o Smoking: previous smoker smoked until age 45 2-3 packs
per day for 20 years, estimated 45 pack year history
o Education: trade school mechanic, high school diploma
o Sexual history, not currently sexually active due to poor
health
Review of Systems (ROS):
There are 14 systems for review*. List positive findings and
pertinent negatives in systems directly related to the systems
identified in the CC and symptoms which are new or have
occurred since last visit;
o (1) constitutional symptoms (e.g., fever, weight loss), pt

reports worsening fatigue and lack of desire to eat or drink, hair,

nails, and skin look to be well taken care of, some dryness noted to
lower extremity possibly related to vascular illness and heart
disease, pt is dressed appropriately, pt allows daughter to do most
communication during exam.
o (2) eyes, pt reports history of cataract with repair, wearing
corrective lenses, pt unsure of strength but states I can see okay
without them denies any symptoms of double or blurred vision.
No redness noted
o (3) ears, nose, mouth and throat, Ears: hearing acuity normal,
denies pain to ears, Nose: Sense of smell intact, no deviation in
septum, denies sinus congestion or epistaxis. Mouth:, teeth appear
normal and intact, mucous membranes moist and pink. Pt reports
brushing 1-2 times daily and denies flossing due to difficulty with
floss, Throat: no sore throat reported, no odor noted, No redness
noted
o (4) cardiovascular, Reports no chest pain palpitations, or edema
that cannot be controlled with a lasix pill, pt does report some
increasing activity intolerance

(5) respiratory, negative cough; negative shortness of breath,

positive history of chronic respiratory diseases, positive smoking

history, negative recent fever or chest congestion
o

(6) gastrointestinal, negative abdominal pain, negative

nausea, negative vomiting, positive diarrhea occasionally,
negative blood in stool, positive acid reflux controlled with
PPI, negative tenderness,
(7) genitourinary, Denies urinary symptoms of nocturia, dysura,

incontinence.
o

(8) musculoskeletal, bilateral knee replacement, denies

any joint stiffness but states he stays in a wheelchair
when outside of his home and uses a walker at home. Pt
reports increased weakness, denies muscle pain, reports
some difficulty with hand strength
(9) integument (skin and/or breast), skin is pale, no
abnormal lesions noted, skin is dry with some patchy
dryness noted to lower legs, pt denies sunscreen use but
states he is barely ever outside, denies rash, nail deformity,

hair loss, bruising

o

(10) neurological, reports new fatigue but denies muscle

weakness, negative, syncopy, stroke, seizure, , tremor, loss of

memory, or severe headaches. Postive paresthesias to lower
extremeties remarks this is not worse than normal
o

(11) psychiatric, negative anxiety, denies depression or

thoughts of self-harm, negative tremor, mood change,
denies difficulty sleeping
(12) endocrine, Denies heat or cold intolerance polydipsia,

polyphagia, polyuria, hair or nails, skin noted to be dry

(13) hematological/lymphatic, denies unusual bruising,
bleeding, transfusion history, history of low magnesium but normal
recently, reports some fatigue and weakness
o (14) allergic/immunologic, Denies any food allergies, denies
recreational allergies, medication allergies as listed above
o

*Refer to the Medatrax comprehensive SOAP guidelines for detail/system.

O: OBJECTIVE DATA: (information you observe with your senses, lab
results, and/or chart notes)

Sufficient physical exam should be performed to evaluate areas

suggested by the history and patient's progress since last visit.
Document specific abnormal and relevant negative findings.
Abnormal or unexpected findings should be described.
Detailed assessment of system(s) that are impacted by CC/HPI.

Record observations for the following systems if

applicable to this patient encounter (there are 12 systems
for examination):
(1) Constitutional (e.g. vita! signs, general appearance),
Vitals: Temp: 97.4 BP: 130/80 Pulse: 72 O2: 95%RA RR: 20
Pain: 0/10 current Ht: 66 Wt: 219 BMI 35.3, General
Appearance is fair to poor, pt appears weak for age, pt in
wheelchair, family speaking in place of patient, but
patient appears to desire this
(2) Eyes, no redness noted, pupils equal and reactive to light,

conjuctiva are nomal, no jaundice noted. No drainage noted.

o

(3) ENT/mouth, EARS, not assessed at this time, due to

no complaints regarding ears, EYES, pupils equal and reactive

to light, conjuctiva are nomal, no jaundice noted. No drainage

noted, NOSE, no drainage from nose, nostrils patent, MOUTH,
dentition normal, mucous membranes moist / pink, lips dry, and
gums normal with no lesions, uvula midline, no odor from mouth,
No exudates noted to back of throat. Tongue is midline and of
normal size.
o (4) Cardiovascular, Heart Sounds Normal S1, S2, no murmurs,
clicks, gallops, Peripheral pulses intact, +1 and non- pitting edema
noted to mid tibial region and down bilaterally
o (5) Respiratory No Cough noted, respiratory effort is unlabored
and regular, lung sounds bibasilar crackles in lower lobes
bilaterally that clears with deep breath and cough. No sputum
noted
o

(6) GI, bowel sounds active throughout, no masses noted,

liver and spleen not palpated, abdomen is soft, large
body habitus, no abdominal tenderness noted, bowel
habits normal per patient, with semi-soft brown stool, no
blood noted per patient
(7) GU, pt denies any dysuria or genitourinary concerns, negative

UA today
o

(8) Musculoskeletal, no bony abnormality noted. Pt denies any

pain to extremeties, back, pelvic cage., pt reports limited ability to

use hands for some activities such as pushing the medication in his
flex pen, pt reports having to get help from his son for this.
o (9) Skin, pale, no lesions noted to visible fields, no rash noted,
skin is warm and dry with good skin turgor, dryness noted
especially below knees bilaterally, no breakdown in skin noted.
o (10) Neurological, pt alert and oriented x3. Decrease sensation
noted to feet. No other gross neurological abnormalities noted on

exam. Pt in wheelchair but states he gets around his home with a

walker,
o

(11) Psychiatric, pt reports weakness and does allow

family to answer question, denies depression and no
history of psychiatric disorder in this patient.
(12) Hematological/lymphatic/immunologic. no evidence of

bruising or bleeding, no jaundice noted., no report of fever, no

reported lymphadenopathy, denies blood in stool.

NOTE: Cardiovascular and Respiratory systems should be

assessed on every patient regardless of the chief complaint.

If is not appropriate to assess each system note that it was

not assessed and why.
Results of any diagnostic or lab testing ordered during that
patient visit. Note results if available or pending.

A: ASSESSMENT / ANALYSIS:
Determine and list the Level of the visit based on the CPT
documentation criteria (separate handout, in Medatrax, and
probably available in clinic)
o Level of Visit 99214
List and number in PRIORITY order the possible diagnoses
(problems) you have identified.
o 1. 250.4 / 250.90 / 357.2 Diabetes Mellitus type 2 with
complications and renal complications, uncontrolled
o 2. 585.3 Chronic Kidney Disease / acute exacerbation due
to uncontrolled Diabetes Mellitus
o 3. 780.7 malaise and fatigue
o 4.V15.81 Noncompliance with medical treatment
o 5. 578.9 Hemorrhage of gastrointestinal tract, unspecified
o 6. 285.29 Anemia of chronic disease
o 7. 599.0 Urinary Tract Infection
Identify the ICD-9 code for each diagnosis
o Identify any procedure codes if appropriate
These diagnoses are the conclusions you have drawn from the
subjective and objective data.
Remember: Your data should support your diagnoses and your
therapeutic plan.

Do not write that a diagnosis is to be "ruled out" rather state the

working definitions (symptoms, probable diagnoses) of patient
problems in the following areas if applicable:

o
o

1. Acute self-limited problems

780.7 malaise and fatigue
V15.81 Noncompliance with medical treatment
2. Chronic health problems
250.4 / 250.90 / 357.2 Diabetes Mellitus type 2 with
complications and renal complications, uncontrolled
585.3 Chronic Kidney Disease / acute exacerbation due to
uncontrolled Diabetes Mellitus

3. Health maintenance
In cases where the diagnosis is already made (follow-up
visits/referrals), state that it is "improved, well-controlled,
resolving or resolved" or that it is "now inadequately controlled,
worsening or failing to change as expected"
o Inadequately controlled chronic conditions should have
possible etiology written (e.g. exacerbation, progression,
side effects of treatment) if known.
o This patient has multiple problems that are / could be
causing his fatigue. Pt has obvious lack of knowledge
about diabetic diet / insulin control / understanding of CBG
number. Pt has history of kidney disease and this may be
further exacerbated in his current state of glucose control.
Pt may also be anemic and could potentially have a GI
bleed. Further evaluation and testing is necessary.

P: PLAN / INTERVENTION / MANAGMENT

Number the interventions to correlate with the diagnoses in the
assessment/analysis section.
Interventions include a number of tests and referrals
To further nail down diagnosis many interventions will take place
o 1,2- CMP and A1C to determine extent of Kidney disease,
and sugar level (Creatinine 2.3, BUN 46, Glucose 305)
(A1C 9.0)
o 4,5,6 CBC, B12, Folate, Iron Saturation and, hemoccult
These will help to determine if any GI bleeding or anemia
which could be causing new onset weakness. (Hemmocult
negative, Iron saturation Folate, B12 WNL, H&H 12.2 and
37.2) (WBC normal)
o 7- Urinalysis to check for urinary tract infection which may
be causing weakness (this was negative at visit for any
blood or WBC)

1, 3- Refer to Diabetic Counseling (pt scheduled for

appointment tomorrow, pt verbalizes he would love to go
to appointment and daughter states she will make sure he
goes and will sit in on the class herself.
5,6 refer to Gastroenterologist in case of continued
anemia, and for cancer screening as scheduled in 2017
earlier If needed.

List actions planned to manage each problem.

o For medications ordered select ONLY (1) medication and
provided detailed information related to: COUMADIN
Indication for this patient: for prevention of blood
clots due to A-Fib
MOA (brief) Interferes with hepatic synthesis of
vitamin K-dependent clotting factors II, VII, IX, and
X, as well as proteins C and S; S-warfarin is 4 times
more potent than R-warfarin
Usual dosage: adjusted per INR, dosages 1-10mg
QHS daily or in intervals like every other day
Available as name brand, generic or both: available
as both
Cost out the medication at 3 different pharmacies
List the names of the 3 pharmacies
contacted
Target: $4
Walmart: $4
Publix: $13.95
Cost of prescription at each pharmacy as
prescribed
o Chronic condition - note the cost for a
30 day supply.
Other interventions to include:
o Outside diagnostic test procedures ordered and why
o As noted above CBC, CMP, B12, Folate, Iron Saturation,
Hemoccult, UA
o Follow-up
Pt to report to ER for any shortness of breath /
chest pain / hypoglycemia or blood sugars greater
than 400.
Patient follow-up should be specified with time or
circumstances of return.
Pt report to Flowers Hospital tomorrow for diabetic
education
Pt to return in 5 days for repeat BMP to evaluate
change in CBG and BUN Creatinine after diabetic

education. If BUN and Creatinine remain elevated

refer to nephrology
INR is 2.1 today, will repeat INR in 4 weeks as
normal routine with no changes in current
coumadin regimen
Consultation/Referrals (if applicable)
Consult Diabetes education program
Consult Gastoenterology for follow-up for potential
GI bleed with new onset fatigue hx gastritis
Consult Home Health to make visits to ensure
patient is doing medication administration properly
for a short term basis
Refer to nephrology if continued worsening of BUN
and Creatinine
Patient education needs (identify all that apply)
Current treatment plan
Make referrals and further management after
result of labs.
Pt to increase insulin by two units per
administration. Pt given handout for
modifying insuline doses based on CBG.
Education given at this time and patient able
to verbalize the instructions with use of the
handout.
Discuss labs for anemia at follow-up.
Health promotion- Consume a well balanced diet
with a mixture of meat, fruits, vegetables and
grains, avoid foods high in sugar, consider initiating
some exercise around the house including walking
for 30 minues 5 x day. Brush teeth twice a day and
recommend getting the floss sticks that make
flossing easier for you. Take medications as
scheduled, avoid tobacco, and alcohol (alcohol will
increase your sugars)
Health maintenance- annual eye exam annual
hearing exam, Annual dental exam, continue to see
your regular doctor and specialists yearly or more
frequently. Depression screening and mini mental
exam testing yearly to ensure no depressive state
or loss in cognition, always wear good fitting shoes
and socks, keep your feet dry, if you have any
cut,callus, or problem with your feet please seek a
health care provider PCP or Podiatrist.
Disease prevention: Colonscopy 2017, Blood
pressure checks at home and with visits, this

patient has not been placed on preventative ASA

because of history of gastritis and on coumadin
therapy, Lipid Panel Q6 months ( pt previous lipid
panel normal 5/14), Avoid tobacco, Fall prevention (
this patient uses a walker currently and has support
systems at home and safety measures include no
rugs on floor and grips/ non slip shower mat, pt
wearing Diabetic shoes. keep Immunizations UTD
(pt receiving prevnar 13 today). Yet to have
shingles immunizations (considering). Influenza
UTD.
Other.
Encourage patient to drink when thirsty and
eat meals at the same time every day and
take insulin at the same time everyday to
prevent further kidney disease, well
maintained sugars and decrease risk of
hypoglycemia
Other interventions that are specific to your patient but not
listed above.
o If patient has continued difficulty with using hands,
consider physical therapy in this patient to maintain
ability to perform ADLs
o Encourage family to allow father to do as much as he
possibly can as far as his ADLs to prevent regression in
daily abilities.