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SOAPE Template for Weekly Group Case Studies_Student

*Documentation is the story of the patient’s healthcare experience and must be precise and complete. When billing for services, the
documentation must support each diagnosis assigned as well as the service provided. Each claim submitted and every service/supply
on the claim must stand alone and be supported by documentation clearly showing the intent of the clinician and the reasons for
performing or ordering the service.

*If you (the family nurse practitioner) forgets to assess anything in the history or physical portion of the exam, you can come back to it
later in the process, but only record data that you have obtained. Failure to document, omitting, or embellishing information has serious
legal implications for your and for the employing organization.

*Do NOT abbreviate. However, it is acceptable to not use complete sentences when charting.

Problem-Focused Visit Elements Results

(S)ubjective Data Chief Complaint (CC:)

The patient tells us a story of their illness. As Family Nurse

Practitioners (FNPs), our job is to create a story of the disease History of present illness (HPI) in OLDCART format:
process that is congruent with the illness narrative. The key
elements of a good history are the same as a good newspaper O
story: who, what, when, and where. L
D
The chief complaint should be a short, direct quote from the C
patient. “My head is killing me!” Aggravating/Associated
R
Remember A in OLDCART stands for either associated T
symptom or aggravating symptoms. Do not use the paragraph,
narrative summary format. List out OLDCART and insert the
relevant information into the framework. Medications:

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Created by Theresa Granger, PhD, MN, ARNP, FNP, NP-C
In most of these case studies, the review of system
information that you will be given is limited. However, it is
important to address the ROS. Supplement what you
know/have been given with relevant review of system
questions related to your chief complaint. Do the best you can,
it gets easier with time and more clinical experience. Do NOT
leave this section out of your SOAP note(s). Develop and
present a focused, relevant review of systems section in your
notes.
Place previous test results in the review of systems section.
(O)bjective Data
This section consists of data and information obtained by the
family nurse practitioner using your senses - eyes, ears, and
hands (aka physical assessment data findings).
If obtained at the time of the examination or immediately
afterward, place laboratory findings and diagnostic test
results in the objective section.
Allergies:
Past Medical history:
Past Family and Social History (PFSH) (taking a social determinants
of health approach). Consider the
neighborhood/housing/surrounding environment, health and health
care access, social and community, education, and economic
stability of the patient and his/her family:
Health Maintenance/Screenings:
Other:
Review of Systems:
The following information has been written into each case study.
Vital signs (T, P, R, BP, and Pain)
General impression
Skin, HEENT, Neck, Heart, Lungs,Abdomen
Genitourinary,Musculoskeletal,Neuro
Other:
Laboratory/Diagnostic Tests
**Depending on the case study or reason for the visit, not all
systems may apply.
(A)ssessment (aka: differential diagnosis)
Assessment refers to the process of pulling together the
findings presented in the subjective and objective sections to
form a diagnosis, which is usually a medical diagnosis that
has a corresponding billing code (ICD-10 for example).
The assessment (diagnosis) section can be divided into two
categories: (1) new diagnoses and preexisting diagnosis and
(2) differential diagnoses – those diagnoses requiring further
testing to confirm.
#1 Priority Diagnosis (most probable, highest priority). Include a
critical review of the relevant subjective and objective data leading
to the conclusion of this diagnosis.
Diagnosis:
Subjective:
Objective:
Review of relevant pathophysiology (1-2 sentences)

If taken correctly with the appropriate questions asked, most

diagnoses can be derived from the history, and to a lesser #2 Differential Diagnosis A. Include a critical review of the relevant
extent, the physical examination and laboratory testing. subjective and objective data leading to the conclusion of this
diagnosis.

Diagnosis:

Subjective:

Objective:

Review of relevant pathophysiology (1-2 sentences)

(P)lan (for the Diagnosis #1, the highest priority diagnosis)
This section outlines the treatment plan related to the chief
complaint, current comorbidities, and/or additional problems
that have become evident during the history taking and
examination process.
Even if you, the FNP, wouldn’t initially refer a patient, address
this section so that your thoughts and rationale are clearly
documented. List exactly who you would refer to
(pulmonologist), when you would refer, and what you expect
this particular practitioner to help with regarding this patient.
Health promotion and health maintenance: Create a specific
Health Promotion section for your plan. This is a major scope
and focus of the FNP role. If you need a refresher on the major
health promotion topics, re-visit the Healthy People 2020
website. The U.S. Preventive Services Task Force website
(http://www.uspreventiveservicestaskforce.org/Page/Name/too
ls-and-resources-for-better-preventive-care) also has helpful
health screening related information.
Follow up: Indicate when patient should return to clinic. Be
sure to give an exact time frame (2 days etc.) AND state
exactly what your intervention will be when the patient returns
(will reassess HEENT looking for improved tonsillar edema,
erythema, and discharge). It is important to have your
thoughts documented – you can’t always assume that your
patient will return to see you. They may return to see another
practitioner and your excellent notes will help to guide this
practitioner and prevent errors/omissions in care for your
patient.
1. Medications prescription (broad classes). Include relevant side
effects/adverse effects/or key points that are important to consider.
2. Medications over the counter (broad classes). Include relevant
side effects/adverse effects/or key points that are important to
consider.
3. Treatments (include alternative medicine recommendations)
4. Diagnostic tests/imaging
5. Interprofessional collaboration (referrals and/or consultation)
6. Social determinants of health
https://www.healthypeople.gov/2020/topics-objectives/topic/social-
determinants-of-health
Domain (Neighborhood/Built environment, Health/Health care,
Social/Community context, Education, Economic stability)
Patient Problem:
FNP Intervention:
7. Health promotion and health maintenance (screening
recommendations/vaccines etc.) recommendations relevant to the
patient: https://www.healthypeople.gov/2020/topics-objectives
HP Topic and Objective:
Patient Problem/Situation:
FNP Intervention:
8. Clinical Preventive Services Guidelines (relevant)
https://www.ahrq.gov/professionals/clinicians-providers/guidelines-
recommendations/guide/index.html

Title of Screening:

Target population:

Recommendation (Grade A, B, C, D, I):

Screening Tests:

Other:

9. Patient education

10. Follow up (at least 5 sentences). When do you want to see the
patient back? What is your plan?
(E)vidence-based practice List at least one relevant evidence-based database or article with
appropriate supporting citation (APA format) used to support your
When working through these case studies, consider one of the differential diagnoses and above plan.
following definitions of evidence-based practice: Evidence-
based practice is "the conscientious, explicit, and judicious
use of current best evidence in making decisions about the
care of individual patients. The practice of evidence based
(nursing) means integrating individual clinical expertise with
the best available external evidence from systemic research."
Retrieved from http://norris.usc.libguides.com/c.php?g=293833

Your entire plan needs to be evidence-based. This means that

you will need to cite evidence for all phases of your plan
(including referrals and follow up).