SOAP Note Assignment
Download and analyze the case study for this week. Create a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.
Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.
28-year-old female presentsto the clinic with a 2 day history of frequency, burning and pain upon
urination; increased lower abdominal pain and vaginal discharge over the past week.
Complains of urinary symptomssimilarto those of previous urinary tractinfections(UTIs) which started
approximately 2 days ago; also experiencing severe lower abdominal pain and noted brown fouls
smelling discharge after having unprotected intercourse with her former boyfriend.
Recurrent UTIs (3 this year); gonorrhea X2, chlamydia X 1; Gravida IV Para III
Past Surgical History
Tubal ligation 2 years ago.
Family: Single; history ofmultiplemale sexual partners; currently lives with newboyfriend and 3
Social: Denies smoking, alcohol and drug use.
Allergy: Trimethoprim (TOM)/ Sulfamethoxazole (SMX) -Rash
Last pap 6 months ago, Denies breast discharge. Positive for Urine looking dark.
T 99.7 F,
Ht 5’ 0”
Gen: Female in moderate distress.
Cardio: Regularrate and rhythm normal S1 and S2.
Abd: soft, tender, increased suprapubic tenderness.
GU: Cervical motion tenderness, adnexal tenderness, foul smelling vaginal drainage.
Laboratory and Diagnostic Testing
Lkc differential: Neutraphils 68%, Bands 7%, Lymphs 13%, Monos 8%, EOS 2%
UA: Starw colored. Sp gr 1.015, Ph 8.0, Protein neg, Glucose neg, Ketones neg, Bacteria – many, Lkcs 10-
15, RBC 0-1
Urine gram stain – Gram negative rods
Vaginal discharge culture:Gramnegative diplococci,Neisseria gonorrhoeae,sensitivities pending
Positive monoclonal AB for Chlamydia, KOH preparation,Wet preparation and VDRL negative
Title of Plan of Care
South University Online
Patient Initials ______
Subjective Data: (Information the patient tells you regarding themselves: Biased Information):
Chief Compliant: (In patient’s exact words)
History of Present Illness: (Analysis of current problems in chronologic order using symptom
analysis [onset, location, frequency, quality, quantity, aggravating/alleviating factors, associated
symptoms and treatments tried]).
PMH/Medical/Surgical History: (Includes medications and why taking, allergies, other major
medical problems, immunizations, injuries, hospitalizations, surgeries, psychiatric history,
obstetric and history sexual history).
Significant Family History: (Includes family members and specific inheritable diseases).
Social History: (Includes home living situation, marital history, cultural background, health
habits, lifestyle/recreation, religious practices, educational background, occupational history,
financial security and family history of violence).
Review of Symptoms: (Review each body system – This section you should place POSITIVE for…
information in the beginning then state Denies…). – General:; Integumentary:; Head:; Eyes: ;
ENT:; Cardiovascular:; Respiratory: ; Gastrointestinal:; Genitourinary:; Musculoskeletal:;
Neurological:; Endocrine:; Hematologic:; Psychologic: .
Vital Signs: BP – ; P ; R ; T ; Wt. ; Ht. ; BMI .
Physical Assessment Findings: (Includes full head to toe review)
Laboratory and Diagnostic Test Results: (Include result and interpretation.)
Assessment: (Include at least 3 priority diagnosis with ICD-10 codes. Please place in order of
Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as
education and counseling provided)
Please use this as one of the references:
From the course textbook, Primary Care: Art and Science of Advanced Practice Nursing–An Interprofessional Approach, read the following chapters:
Common Endocrine and Metabolic Disorders
Common Hematological Immunological Complaints
Common Urinary Complaints
From the course textbook, A Manual of Laboratory and Diagnostic Tests, read the following chapters:
Design a holistic patient care plan. Utilize the SOAP guidelines to assist you in creating your SOAP note and building your plan of care. You are expected to develop a comprehensive SOAP note based on the given assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan. If the information is not in the provided scenario please consider it normal for SOAP note purposes, if it is abnormal please utilize what you know about the disease process and write what you would expect in the subjective and objective areas of your note.
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