Practicum: SOAP Note and Time Log
Select a patient whom you examined during the last three weeks. With this patient in mind, address the following in a SOAP Note:
• Subjective: What details did the patient provide regarding her personal and medical history?
• Objective: What observations did you make during the physical assessment?
• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
• Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
• Reflection notes: What would you do differently in a similar patient evaluation?
Resources
• Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for midwifery & Women’s health (4th ed.). Burlington, MA: Jones & Bartlett Publishers.
o Chapter 7, “Care of the Woman with Reproductive Health Problems”
“Care of the Woman with an Abnormal Pap Smear” (pp. 333–341)
This section examines management strategies for abnormal pap smears, focusing on the implementation of evidence-based guidelines. It also describes the roles that physical examinations and diagnostics play in treatment and management decisions.
“Care of the Woman with Bacterial Vaginosis” (pp. 344–347)
This section identifies the presentation and incidence of bacterial vaginosis and provides strategies for diagnosing and treating this infection.
“Care of the Woman with Chlamydia” (pp. 352–354)
This section describes the presentation and impact of chlamydia on women. Chlamydia screenings and strategies for diagnosis and treatment are also examined.
“Care of the Woman with Gonorrhea” (pp. 378–381)
This section explains the presentation of gonorrhea and its association with chlamydial infections. It also presents strategies for diagnosing and treating patients with this condition.
“Care of the Woman with Hepatitis” (pp. 381–385)
This section identifies the five primary types of hepatitis infections, including appropriate treatment options and recommended follow-up care.
“Care of the Woman with Herpes Simplex Virus” (pp. 385–388)
This section examines the herpes simplex virus, including transmission of the condition, special considerations for pregnant women, and recommended treatment and management strategies.
“Care of the Woman with Human Immunodeficiency Virus” (pp. 389–393)
This section explores HIV, transmission of the condition, diagnosis, long-term treatment, and implications for women. It also describes the potential impact of the condition on pregnant women and their newborns.
“Care of the Woman with Human Papillomavirus” (pp. 393–396)
This section describes the prevalence of HPV and its impact on women. It also identifies screening tests for HPV as well as clinical management guidelines for HPV-infected patients.
“Care of the Woman with Parasitic Infestation” (pp. 399–402)
This section explains difficulties of treating and preventing parasitic infestations, including lice and scabies.
“Care of the Woman with Syphilis” (pp. 418–421)
This section identifies possible presentations of syphilis. It also presents treatment options for managing this condition, as well as special considerations for pregnant women and their newborns.
“Care of the Woman with Trichomoniasis” (pp. 421–424)
This section explores the presentation, impact, and treatment of trichomoniasis on women. It also identifies follow-up care guidelines for patients with this infection.
“Care of the Woman with Vulvovaginal Candidiasis” (pp. 424–427)
This section examines the prevalence of vulvovaginal candidiasis, as well as factors that may contribute to a diagnosis of this condition.
• Centers for Disease Control and Prevention. (2010a). Sexually transmitted diseases treatment guidelines, 2010. Morbidity and Mortality Weekly Report, 59(RR-12). Retrieved fromhttp://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf
This article provides guidelines for treating patients with sexually transmitted diseases, including HIV, syphilis, chlamydia, and HPV. The care of special populations of women is also discussed.
Optional Resources
• Centers for Disease Control and Prevention. (2012b). Women’s health. Retrieved fromhttp://www.cdc.gov/women/
• National Institutes of Health. (2012). Office of Research on Women’s Health (ORWH). Retrieved fromhttp://orwh.od.nih.gov/
• U.S. Department of Health and Human Services. (2012a). Womenshealth.gov. Retrieved fromhttp://www.womenshealth.gov/
SAMPLE OF LAST SOAP NOTE; PLEASE FOLLOW SAME FORMAT
SOAP Notes
Purpose: The goal of the soap note is to assist the nurse practitioners in documenting the patient care, from observation to treatment to conclusion. In this soap note, the issue of Urinary Stress Incontinence in the Women’s Health is comprehensively discussed. Moreover, in order to achieve the desired outcome of the holistic care, the medical diagnosis of the patient is provided and thoroughly elucidated.
SUBJECTIVE DATA:
Chief Complaint (CC): Complaints of urine leakage
History of Present Illness (HPI): 44-year-old Caucasian female that complains of urine leakage that keeps occurring in her daily activities. She stated that the urine leakage began approximately 2 years ago. According to her, it already progresses to the point that she is using 3 pads per day. She is bothered by the condition because it happens mainly in her chores around the house. In addition, she also stated that there is also involuntary loss of urine on forceful sneezing, coughing and jumping. She has 3 children making, her Gravida 3 and Para 3 in her pregnancies. All of them were delivered vaginally and uncomplicated. She is on a healthy diet. However, her body mass index is 35 kg/ m2 which classifies as obese. Her medical history revealed that she had hypertension and diabetes. Currently, she is taking hydrochlorothiazide (Microzide®) 25 mg. Nine years ago, she had partial hysterectomy. She is menstruating normally and has no other urinary symptoms.
Medications: hydrochlorothiazide (Microzide®) 25 mg per day
Allergies: No known allergies
Past Medical History (PMH): Past hospitalization is caused by hypertension and diabetes
Past Surgical History (PSH): Patient undergone vaginal hysterectomy 9 years ago
OB/GYN History (if applicable): The patient is Gravida 3 and Para 3. Delivery was Normal Spontaneous Vaginal Delivery. No menustration. Patient’s contraceptive methods include hysterectomy. Patient reports possible minor leakage in the point of orgasm in sexual intercourse.
Personal/Social History: As for the patient’s personal history, she stated that she loves to eat sweets and in fast foods before. She is not very active and she does not usually do exercise. She is not smoker. She drinks alcohol occasionally.
Immunizations: Last Tdp 10-2013, Flu 10-18-2014, and pneumonia immunizations 8-2010 is up to date
Family History: Father-HTN, Mother- Diabetes
Review of Systems:
General: the patient denies fatigue, fever, weakness, chills, problem in sleeping, weight loss and weight gain.
Skin: the patient denies rashes, lumps, sores, itching, dryness, changes, etc.
HEENT: Head- The patient denies headache, head injury and pain. Eyes- the patient report very seldom blurring of vision. The patient denies redness, loss of vision, pain, dryness, flashing lights, and denies use of eyeglasses. Ears- the patient denies ear discharge, loss of hearing and ringing in the ears. Nose- the patient denies nosebleeds, dry sinuses, loss of smell, sinusitis and nasal drip. Mouth- the patient denies sore tongue, sore mouth, bleeding gums, loss sense of taste, dentures, dry mouth, hoarseness of voice, painful swallowing and acid and bitter taste in mouth.
Neck: The patient denies neck injury, stiffness and neck pain.
Breasts: The patient denies lumps, pain and other discharges.
Respiratory: The patient denies chronic dry cough, cough with blood, repeated pneumonias, night sweat and wheezing.
Cardiovascular: The patient reported hypertension. The patient denies chest pain, irregular heartbeats, palpitation, SOB and heart murmur.
Gastrointestinal: The patient denies loss of appetite, nausea, vomiting, blood vomiting, heart burn, regurgitation, stomach pain, belching, jaundice, constipation, diarrhea, blood in stools, hemorrhoids.
Peripheral vascular: The patient denies swollen legs and feet and varicose veins
Urinary: The patient reports of leakage of urine in ADL and other activities. The patient denies difficulty in urination, pain in urination, blood in urine, frequent urination, kidney stones and ulcers.
Genital: the patient denies sexual difficulties and STDs
Musculoskeletal: The patient denies cramping in arm, buttocks and thigh. The patient denies pain, weakness and tenderness, joint swelling and major orthopedic surgeries.
Psychiatric: The patient denies depression, suicidal ideation, counseling and special treatments.
Neurological: The patient denies dizziness, headache, fainting, loss of consciousness, memory loss and sensitivity to hands and feet.
Hematologic: The patient denies anemia and problems in clotting tendencies and bleeding tendencies.
Endocrine: The patient denies flushing, fingernails changes, increase thirst, increase salt intake and intolerance to hot and cold.
OBJECTIVE DATA:
Vital Signs: Axillary temperature of 36.9 ° C, Respiratory rate of 20, Heart rate of 87 with regular rhythm and Blood Pressure of 130/90.
BMI: 35 kg/ m2
General: a 44-year-old obese female who is awake, alert and appears healthy with good posture, grooming, and looks at her age.
SKIN: the patient’s skin appears uniform in color and no presence of foul odor. Good skin turgor and temperature are in normal limit.
HEENT: Head- normocephalic and symmetrical head. Eyes- white sclera, pink conjunctiva, transparent cornea, PEERLA, parallel movement of eye balls, no edema. Ears- firm and non-tender auricles, no lesions, no palpable masses. Nose-symmetric nose, with uniform color, no presence of discharges, no nasal flaring, no tenderness and no lesions. Tongue and mouth- uniform , moist, symmetric lips. Pinkish color in gums, tongue centrally positioned and uvula in the midline.
Neck: Head movements are coordinated and without discomfort, lymph nodes not present.
Chest/Lungs: Chest wall appears intact and without tenderness, full symmetric expansion, percussion without rales, rhonchi, wheezing and diminished breath sounds, quiet, rhythmic and effortless respirations.
Heart/Peripheral Vascular: regular rhythm, no visible pulsation, no jugular vein distention, no presence of lifts or heaves. Normal s1 and s2 sounds, no s3, s4 and murmurs, no peripheral edema, no cyanosis, no pallor, capillary refill less than 2 seconds.
Abdomen: positive bowel sounds, soft, non-tender, non-distended abdomen, no rebound, no guarding and no masses.
Genital: pelvic examination reveals absence of inflammation, atrophy and infection, absence of paleness and thinness. Presence of urine leakage in activities. Bimanual examination shows the patient hold the contraction for levator ani muscle contraction function for 4 seconds. Pyridium test reveals urine loss.
Musculoskeletal: firm and coordinated muscles, no presence of bone deformities, tenderness and swelling
Neurological: CN II-XII are intact and functioning well, strength and sensation are symmetric and intact throughout, reflexes 2+ throughout and cerebellar testing is normal.
ASSESSMENT:
Primary Diagnosis: Stress Urinary Incontinence
Differential Diagnosis:
Excessive Urine Output (hypertension, high blood sugar levels, possible primary polydipsia)
Urinary Obstruction (Anatomical Obstruction, obesity, possible fluid overload caused by hypertension)
Acute Urinary Tract Infection (advanced age, immunosuppression, and vaginal hysterectomy) Vasavada 2014, p. 1)
Previous diagnosis: Controlled HTN and Controlled diabetes (regular intake of hydrochlorothiazide (Microzide®) and low sugar diet.
PLAN: the goal for optimal therapy is to lessen the number of incontinence episodes through the help of combinations of treatment strategies.
Physician orders:
• Physical examination to assess vaginal prolaspe, vaginal turgor and neurologic condition evaluation.
• Urinalysis evaluates pyuria and hematuria.
• Post-Void Residual is needed to rule out overflow incontinence
• Cystoscopy for visualization of urethral and bladder lumen’s signs of anatomical abnormalities
• Urodynamic studies to confirm SUI, assess urethral function, assess the urgency incontinence and evaluate compliance.
Non pharmacological therapies
• Lifestyle modifications- weight management and dietary changes including sweets, fatty, caffeinated products, acidic and spicy products because it could adverse the bladder function.
• Behavioral Therapies- it comprises patient education about the lower urinary tract functions, bladder training, time voided, fluid and dietary management, voiding log or diary and Kegel exercises. The rationale is to help the patient regain control of the bladder by increasing the capacity of the bladder.
• Pelvic Floor Muscle Training- helps the patient to strengthen the muscle of the pelvic floor.
• Electrical Stimulation-external application of electrical current to provide a passive contraction to stimulate reinnervation of the pelvic floor.
• Vaginal cones- a device that looks like a tampon that is inserted in the vagina to trigger a sensory feedback that results in muscle contraction of the pelvic floor.
• Extraurethal Occlusive devices- includes Miniguard®, FemAssist® , CapSure™ that aims to block leakage of urine.
• Intraurethal occlusive devices- devices that are inserted directly to the urethra to block the urine flow into the proximal urethra (Rovner 2004, p. 40).
Pharmacologic therapy
• α-Adrenergic Agonists- induces muscle contraction when stimulated
• Imipramine- a tricyclic antidepressant that aids as facilitator of storage of urine that increases outlet resistance.
• Duloxetine- enhances urethral activity by suppressing the bladder activity through a mechanism in the central serotonin receptors.
• Hormonal therapy- sex steroid influences continence in many ways. It increases urethral outlet resistance by generating urine storage for postmenopausal patients.
Follow up/ monitoring
• In non-pharmacological therapy, follow up will be in 3 months if the patients are not satisfied with the results.
• In pharmacological therapy, follow up is 1-2 weeks for medication response assessment especially to the older adults because of significant adverse effects.
Referrals
• Refer to Gynecology or Urology if the patient desires further assessment, evaluation and treatment and/or under surgery for incontinence
• Refer to Gynecology if there is a presence and symptoms of uterine prolapsed and other gynecological problems
• Refer to Urology if there are recent neurological changes
• Refer to PT if the patients do not understand the Kegels and other pelvic exercise is done.
Consultations
• Immediate consultation if other gynecological signs and symptoms occur.
Health Promotion:
• Encourage a healthy eating diet; low fat, low salt, low cholesterol, moderate sugar, high fiber, high carbohydrates, plenty of water for continuous management of the hypertension and diabetes.
• Keep a regular exercise to increase muscle strength and maintain body balance.
• Set precautionary measures to emphasize safety.
• Participate in different programs such as national action plan continence program to prevent and eradicate incontinence (Group Health Cooperative, 2013, p. 7).
Disease Prevention
• Keep a regular diet
• Cough stress test to assess the recurrence of the incontinence
• Muscle strength test to monitor overall muscle strength
• Various bladder test to check any associated problems.
REFLECTION:
One way to enhance the quality of care is through the use of soap notes. It gives me an idea that soap notes provides a quick, efficient and accessible record that can track overall progress of the patient. Soap note for women’s health issue augments my understanding about women’s wellbeing and increase my knowledge about the interventions, promotions and preventions to deal with the diseases. Since soap notes encourage holistic approach, it grounds the action plans to the evidences presented. I totally agree with the preceptor because it will defend me against malpractice by keeping tracks and records. The one thing I would have done differently is to have my patient keep a diary for one week of her urine output. This would have clued the nurse practitioner of how much urine output the patient was actually putting out. I would also recommend that the patient train herself to use the bathroom every 2-3 hours to control the incontinence. In my own clinical practice, soap notes have given me a chance to improve my competence. It encourages me to work closely to my scope of practice. In clinical settings, soap notes can be considered as complementary to nurse’s notes because these maintained progress notes could alert all health care providers, focusing particularly on care.
References
Group Health Cooperative (2013). Urinary Incontinence in Women Guideline. Retrieved
December 17, 2014 from https://www.ghc.org/all-sites/guidelines/incontinence.pdf.
Rovner, E. S. & Wein, A. J. (2004). Treatment Options for Stress Urinary Incontinence. Reviews
in Urology, 6(3), S29–S47.
Vasavada, S. P. (2014). Urinary Incontinence Differential Diagnoses. Medscape. Retrieved
December 17, 2014, from http://emedicine.medscape.com/article/452289-differential.
Is this the question you were looking for? If so, place your order here to get started!
