Soap Note About a Child with Bronchitis Worksheet

I’m studying for my Nursing class and don’t understand how to answer this. Can you help me study?

Label each section of the SOAP note (each body part and system).

Do not use unnecessary words or complete sentences

Use Standard Abbreviations 

SUBJECTIVE DATA (information the patient/caregiver tells you).

Chief

Complaint (CC): a statement describing the patient’s symptoms, problems,

condition, diagnosis, physician-recommended return(s) for this patient visit.

The patient’s own words should be in quotes. 

History

of present illness (HPI): a chronological description of the development of the

patient’s chief complaint from the first symptom or from the previous encounter

to the present. Include the eight variables (Onset, Location, Duration,

Characteristics, Aggravating Factors, Relieving Factors, Treatment,

Severity-OLDCARTS), or an update on health status since the last patient

encounter. 

Past

Medical History (PMH): Update current medications, allergies,

prior illnesses and injuries, operations and hospitalizations allergies,

age-appropriate immunization status. 

Family

History (FH):

Update significant medical information about the patient’s family (parents,

siblings, and children). Include specific diseases related to problems

identified in CC, HPI or ROS. 

Social

History(SH): An

age-appropriate review of significant activities that may include information

such as marital status, living arrangements, occupation, history of use of

drugs, alcohol or tobacco, extent of education and sexual history. 

Review

of Systems (ROS). There are 14 systems for review. List positive

findings and pertinent negatives in systems directly related to the systems

identified in the CC and symptoms which have occurred since last visit; (1)

constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose,

mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal,

(7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast),

(10) neurological, (11) psychiatric, (12) endocrine, (13)

hematological/lymphatic, {14) allergic/immunologic.  The ROS should mirror the PE findings

section.

OBJECTIVE DATA (information you observe, assessment findings, lab results). 

Sufficient

physical exam should be performed to evaluate areas suggested by the history

and patient’s progress since last visit. Document specific abnormal and

relevant negative findings. Abnormal or

unexpected findings should be described. You should include only the

information which was provided in the case study, do not include additional

data. 

Record

observations for the following systems if applicable to this patient encounter

(there are 12 possible systems for examination):

Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth,

Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological,

Psychiatric, Hematological/lymphatic/immunologic/lab testing.   The focused PE should only include systems

for which you have been given data.  

NOTE: Cardiovascular and Respiratory

systems should be assessed on every patient regardless of the chief complaint.

Testing

Results: Results of any diagnostic or lab testing ordered during that patient

visit.

ASSESSMENT:  (this is your diagnosis (es) with the

appropriate ICD 10 code) 

List

and number the possible diagnoses (problems) you have identified. These

diagnoses are the conclusions you have drawn from the subjective and objective

data.  

Remember: Your subjective and objective data should

support your diagnoses and your therapeutic plan.

Do

not write that a diagnosis is to be “ruled out” rather state the

working definitions of each differential or primary diagnosis (es).

For

each diagnoses provide a cited rationale for choosing this diagnosis. This

rationale includes a one sentence cited definition of the diagnosis (es) the

pathophysiology, the common signs and symptoms, the patients presenting signs

and symptoms and the focused PE findings and tests results that support the dx.

Include the interpretation of all lab data given in the case study and explain

how those results support your chosen diagnosis. 

P:

PLAN (this is your treatment plan specific to this

patient). Each step of your plan must include an EBP citation. 

1.

Medications write out the prescription including dispensing

information and provide EBP to support ordering each medication.  Be sure to include both prescription and OTC

medications.  

2.

Additional diagnostic tests include EBP citations to support

ordering additional tests