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Unit 6
●Case: Lara Taylor
●Scenario Description: The patient is a 35 year old c
Unit 6
●Case: Lara Taylor
●Scenario Description: The patient is a 35 year old caucasian female who comes for a routine prenatal visit – regular visit at 20 weeks
CC: should be written in the patients own words as a direct quote.
HPI: patient reported always having irregular cycles so you cannot state ” no previous history”. Patient also reported trying to conceive x 1 year. You need to include details about her menstrual cycle irregularities.
Medications: patient is taking prenatal vitamins.
Allergies: pt did not report a dust allergy, she reported a sulfa allergy.
Family history: sister as diabetes, father has hypertension.
Remove the assignment instructions for the ROS header before submitting your assignment.
ROS:
Objective:
Labs: also copmleted CMP, FSH, LH, lipids, prolactin, HCG, DHEA-S and SHBG. Results should be included for all labs.
DDX: more detail needed to support each DDX and final dx.
Plan-medications: pt should also be prescribed metformin.
Diagnostic tests: List specific tests you would order.
Referrals:
References: refrain from using any reference that is more than 5 years old. You would have greatly benefited from using your textbook as a reference.
The core aspects of the SOAP note are described in detail below.
S: Subjective information. Everything the patient tells you. This includes several areas, including the chief complaint (CC), the history of present illness (HPI), medical history, surgical history, family history, social history, medications, allergies, and other information gathered from the patient. A commonly used mnemonic to explore the core elements of the history of present illness (HPI) is OLD CARTS, which includes: Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatments, and Severity.
O: Objective is what you see, hear, feel or smell. Your physical exam, including vital signs.
A: Assessment/your differentials
P: Plan of care including health promotion and disease prevention for the patient related to their age and gender.
This assignment will demonstrate your ability to provide age-appropriate anticipatory guidance while recognizing the need to refer patients that are outside of the scope of practice of the family nurse practitioner. This will be demonstrated by completing a SOAP note based on the virtual reality patient you evaluated in Unit 4..
Write-ups
The SOAP note serves several purposes:
It is an important reference document that provides concise information about a patient’s history and exam findings at the time of patient visit.
It outlines a plan for addressing the issues which prompted the office visit. This information should be presented logically and prominently features all of the data that’s immediately relevant to the patient’s condition.
It is a means of communicating information to all providers involved in the care of a particular patient.
It allows the NP student to demonstrate their ability to accumulate historical and examination-based information, use their medical knowledge, and derive a logical plan of care.
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