This example demonstrates a well-structured SOAP note from a Nurse Practitioner (NP) following a patient encounter. Remember, this is an example and specific details will vary greatly depending on the patient and their condition. Always adhere to your institution's guidelines and legal requirements when documenting patient care.
Patient: Jane Doe, 45-year-old female
Date: October 26, 2023
Time: 10:00 AM
S: Subjective
- Chief Complaint (CC): "Persistent cough and shortness of breath for the past two weeks."
- History of Present Illness (HPI): Patient reports a persistent, non-productive cough that began two weeks ago. She describes the cough as being worse at night and is accompanied by shortness of breath, particularly with exertion. She denies fever, chills, or chest pain. She reports feeling increasingly fatigued over the past week. She denies any recent travel or exposure to sick individuals. She states she has been experiencing occasional wheezing.
- Past Medical History (PMH): Asthma (diagnosed at age 10, well-controlled with albuterol inhaler as needed), seasonal allergies.
- Past Surgical History (PSH): Tonsillectomy at age 5.
- Medications: Albuterol inhaler (prn)
- Allergies: NKDA (No Known Drug Allergies)
- Social History: Patient is a non-smoker. She reports drinking alcohol socially (1-2 glasses of wine per week). She denies illicit drug use. She works as a teacher and reports moderate stress levels.
- Family History: Father with history of hypertension and coronary artery disease; mother with history of osteoporosis.
O: Objective
- Vital Signs: BP 120/80 mmHg, HR 90 bpm, RR 22 breaths/min, Temp 98.6°F (oral), SpO2 95% on room air.
- Physical Exam: General appearance appears slightly fatigued. Lungs reveal scattered wheezes bilaterally. Heart sounds are regular rate and rhythm with no murmurs, rubs, or gallops. No edema noted in lower extremities. Throat examination is unremarkable.
- Laboratory Data (if applicable): None obtained at this visit. Considered based on clinical presentation.
A: Assessment
- Possible Diagnosis: Likely exacerbation of asthma. Possible upper respiratory infection.
P: Plan
- Diagnostics: Peak expiratory flow (PEF) measurement. Chest X-ray if symptoms do not improve within 48-72 hours or if significant worsening occurs.
- Treatment:
- Instruct the patient in proper use of her albuterol inhaler.
- Prescribe a 5-day course of prednisone 40mg daily to reduce inflammation.
- Recommend increasing fluid intake.
- Advise patient to avoid known allergens and irritants.
- Patient education regarding asthma triggers and management techniques.
- Schedule follow-up appointment in one week to assess response to treatment.
- Patient Education: Thorough explanation of the diagnosis, treatment plan, and potential complications. Instructions on medication use and when to seek immediate medical attention. Importance of adherence to the treatment plan.
Frequently Asked Questions (PAA) Addressing Potential Queries:
What information should be included in a nurse practitioner's SOAP note?
A complete SOAP note from an NP includes subjective information (patient's statements), objective findings (physical exam, vital signs, lab results), assessment (diagnosis and rationale), and plan (treatment, diagnostics, and patient education). All information should be clearly documented and concise.
How detailed should a SOAP note be?
The level of detail in a SOAP note should be sufficient to provide a clear and comprehensive picture of the patient's encounter. Omit unnecessary information, but be thorough enough to accurately reflect the patient's condition and the NP's clinical judgment.
Are there legal implications for inaccurate or incomplete SOAP notes?
Yes, inaccurate or incomplete SOAP notes can have significant legal implications. They can be used as evidence in malpractice lawsuits, and failure to accurately document patient care can lead to disciplinary actions. Therefore, meticulous documentation is critical.
What is the difference between a SOAP note and a progress note?
While both document patient encounters, a SOAP note follows a specific structure (Subjective, Objective, Assessment, Plan) whereas a progress note may take a more narrative form. Progress notes often document changes in a patient’s condition over time.
This example showcases a comprehensive SOAP note. Remember to tailor each note to the individual patient's unique needs and circumstances. Always consult relevant guidelines and best practices in your area.
