Nur 6531

For this Assignment, you will work with a patient with a gastrointestinal condition that you examined during the last three weeks. You will complete your second Episodic/Focused Note Template Form for this course where you will gather patient information, relevant diagnostic and treatment information, and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, PMH, socioeconomic, cultural background, etc. In this week’s Learning Resources, please review the Focused Note resources for guidance on writing Focused Notes.
Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using SAFE ASSIGN.
Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.
To prepare:

• Use the Episodic/Focused Note Template found in the Learning Resources for this week to complete this Assignment.
• Select a patient that you examined during the last three weeks based on any gastrointestinal conditions. With this patient in mind, address the following in a Focused Note:

Assignment:

• 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?

Note: Your Focused Note Assignment must be signed by Day 7 of Week 6.
Some Expert Guidance in Writing SOAP Notes
What Does SOAP Stand For?
SUBJECTIVE
 
The initial portion of the SOAP note format consists of subjective observations. These are symptoms the patient verbally expresses or as stated by a significant other. These subjective observations include the patient’s descriptions of pain or discomfort, the presence of nausea or dizziness, when the problem first started, and a multitude of other descriptions of dysfunction, discomfort, or illness the patient describes. OBJECTIVE
 
The next part of the format is the objective observation. These objective observations include symptoms that can actually be measured, seen, heard, touched, felt, or smelled. Included in objective observations are vital signs such as temperature, pulse, respiration, skin color, swelling and the results of diagnostic tests. ASSESSMENT
 
Assessment follows the objective observations. Assessment is the diagnosis of the patient’s condition. In some cases the diagnosis may be clear, such as a contusion. However, an assessment may not be clear and could include several diagnosis possibilities.
PLAN
 
The last part of the SOAP note is the health care provider’s plan. The plan may include laboratory and/or radiological tests ordered for the patient, medications ordered, treatments performed, patient referrals (sending patient to a specialist), patient disposition (e.g., home care, bed rest, short-term, long-term disability, days excused from work, admission to hospital), patient directions (e.g. elevate foot, RTO 1 week), and always include follow-up directions for the patient.
What is a SOAP Note?
The SOAP note format is used to standardize medical evaluations that are made in clinical records.
 
The SOAP note is written to facilitate improved communication among all involved in caring for the patient and to display the assessment, problems and plans in an organized format.
 
Many Electronic Health Records (EHR) systems are capable of producing SOAP Notes. The actual notes and other information are commonly referred to as Electronic Medical Records (EMR).
What are the components of a SOAP note?
 
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. The length and focus of each component of a SOAP note varies.
Subjective component
This describes the patient’s current condition in narrative form. The history or state of experienced symptoms is recorded in the patient’s own words.
It will include all pertinent and negative symptoms under review of body systems in addition pertinent medical history, surgical history, family history, social history along with current medications and allergies are also recorded.
The primary care provider seeing the patient will take a History of Present Illness or HPI. To structure this portion of the note, you can use another mnemonic: OLD CARTS
· Onset
· Location
· Duration
· Character (sharp, dull, etc.)
· Alleviating/Aggravating factors
· Radiation
· Temporal pattern (every morning, all day, etc)
· Symptoms associated
Objective component
The objective component includes:
· Vital signs (including pain scale, pulse oximetry readings)
· Findings from physical examinations, such as posture, bruising, and abnormalities
· Results from laboratory tests
· Measurements, such as age and weight of the patient.
Assessment
This section is where you write your diagnosis, or, if more than one, your diagnoses.
Some assessments also require a quick summary note of the patient with main symptoms/diagnosis. Some include a differential diagnosis (but most do not), which is a list of other possible diagnoses usually in order of most likely to least likely.
Source: Physician SOAP Notes (2015). Retrieved from: http://www.physiciansoapnotes.com/

 Guidelines for SOAP (Post Encounter Notes)

Another good source for explaining how to write SOAP Notes
Introduction: “If it ain’t written down, it didn’t happen”
Good notes are essential in primary care to document changes over time that can be crucial to diagnosis and management. Thinking about the note ahead of time can improve the patient encounter.
SOAP notes are legal documents that are taken as the formal, complete record of the encounter.
Strong Hints:
1. Practice talking to patients in order to collect all pertinent data for each section at the same time.  This will aid in a smooth transition between sections.
2. Practice, practice, practice until you have comfortable phrases and sets of questions that work well for you.
3. As you finish the patient encounter “think SOAP note”. Mentally scan the expected SOAP note sections and check you have all the necessary data.
4. Organize your thoughts before starting the note so your writing time is used efficiently. Using the same phrases each time can help.
5. Be very careful about abbreviations.
6. Always be truthful – never record anything in the SOAP note that you did not do or ask.
Specific Components of the SOAP Note
History (Subjective):
Ask your patient pertinent positives and negatives from HPI, PMH, ROS, FH, SH. It is strongly suggested that you write these headings in the left margin of your note before starting as once you start to write the note, it is easy to miss a specific subheading.
HPI: Start with the age, sex, race using the formula of age, sex, race and chief complaint. e.g.
“Patient is a 40 year old white female complaining of (or presenting because of)”. If using a patient quote, mark it appropriately.
HINTS:
· Completely, succinctly describe the presenting complaint.
· Memorize a template for common problems, if possible.
· Use the mnemonics or whatever helps you to remember a “script” for common symptoms/conditions, especially pain.
· Address the pertinent positives and negatives for the specific system in the HPI for completeness (e.g. include shortness of breath, ankle swelling, etc. in a presenting complaint of chest pain)
· It is a good practice is to end with what the patient thinks or fears as the cause of symptoms.
PMH:
1. Serious illness, hospitalization, surgery
2.  Medications (includes prescriptions, OTC and herbs/supplements) give dose and duration of use if known
3. Allergies (frequently forgotten!!!)
4. Status on preventive issues – Immunizations, Pap, mammogram, colon screening, etc.
5. Always document reproductive basics in women e.g. G2P2LC2. Menarche aged 12, regular cycles 3-4/28 no clotting/cramping. Contraception by tubal ligation. In postmenopausal woman, give age and any HRT use
SH:
1. Tobacco, alcohol, substances (duration and amount of use) Check for ex-users. Be sure to ask in patients you don’t suspect of “vices”. If you get a positive response, you need to do a more detailed history for alcohol or tobacco or substance.
2. Occupation and/or educational history (just key issues, mainly exposures and stressors).
3. Living situation (who lives at home, any stressors, sexually active).
4. Health habits especially diet and exercise but can include hobbies.
 
FH:
1. Cause of death/significant health problems for parents
2. Significant health problems in siblings
3. Close relatives with heart disease, stroke, diabetes, hypertension, cancer or “anything that runs in the family”
4. Other questions depend on case – e.g. ask more in a breast cancer case about relatives with cancer or ask about sudden deaths in a palpitations case.
ROS:  Brief scan of key symptoms in each system. Don’t forget mood!
Physical Exam: (Objective)
You are required to do focused physical examinations. You must select which systems to examine based on the data required to diagnose and/or manage the case. If you do too much PE, you are taking time away from history and negotiation with the patient. The key exams are:
1. Vital Signs
2. General Impression of Patient:
HINT: Lots of individual variation in how this is recorded. Keep this brief but comment on:
1. Appearance (body habits). Mainly weight (obese, overweight, thin, appropriate for height). In some cases, signs of recent weight loss are relevant.
2. Distress/pain. General appearance and apparent severity of pain or distress and relevant issues such as holding a specific body part, restless, or unwilling to move for pain e.g. “appears to be in severe pain, lying still with knees drawn up.”
3. General affect/demeanor. Usually focuses on anxiety or depression. Can include general cooperation or ability to answer questions as “alert, pleasant, upbeat, very talkative”. elderly lady; also used to document anger, hostility, use of inappropriate language.
4. Other pertinent issues. Specific issues relevant to each case e.g. skin tones – pale, jaundiced, plethoric (rashes and obvious external lesions should have a specific entry in PE): sweating or shivering: smells (e.g. ketotic, alcohol): clothes and grooming may be important as clinical indicators e.g. of self-neglect.
3. Pertinent System(s) Exam:
Systematically record the pertinent positive and negative findings for the systems(s) you examine using subheadings to organize your findings. In conditions like diabetes and hypertension that cause systemic damage, prioritize the target organs like fundi, heart size, peripheral nerves and circulation.
4. Any Specific Exams:
Special items may be appropriate to individual cases.  If necessary, do not hesitate to ask the patient for permission to do a “sensitive” examination (breast, prostate, rectal, pelvic) and document the information you receive.
If the patient does not consent but you still think the data from the exam is necessary, document “refused” or “declined” and put “arrange pelvic (or other sensitive) exam” in the diagnostic plan.
Differential Diagnosis (Assessment)
In assessment you synthesize the data you have collected from the H&P into plausible medical explanations AND your sense of the most probable diagnoses for this presentation in the specific type of patient seen (e.g. severe RIQ abdominal pain could be caused by appendicitis in a child, ovarian or tubal conditions in a woman of reproductive age, diverticular disease in an elder, inguinal hernia in a young man).
HINT:
1. Name specific medical diseases or conditions and use correct medical terminology and spelling – do not repeat symptoms in your assessment.
2. The conditions should be listed in order of probability – you have to commit!
3. The evidence for the conditions listed must be in the note. For example, you cannot list depression if relevant signs, symptoms, history have not been subjectively reported or objectively seen and documented.
Diagnostic Plan.
Diagnostic tests can include:
· laboratory tests
· imaging studies
· questionnaires and special tests like psychometric or pulmonary function
· specific data gathering such as obtaining BP measures at community sites, keeping pain or symptom  or food intake diary
Also in the diagnostic plan are:
· Specific treatments (e.g. Medications – use generic names and be as specific as possible regarding dose, length of therapy, how it should be used etc.)
· Ancillary treatments such as physical, occupational therapies
· Patient/family education
· Community support/resources
· Prospective care/preventive services
· FOLLOW UP (this is essential!)
Resources
The USMLE-CS website has information and shows the templates for notes:
http://www.usmle.org/Examinations/step2/cs/content/appendixB.html
http://www.usmle.org/examinations/step2/cs/2009CSinformationmanual.pdf
 

Sample Write-Up (THIS SAMPLE IS VERY EXTENSIVE, DON’T BE AFRAID)

Patient ID: Mr. H
Chief Complaint: Abdominal pain

History of Present Illness

Mr. H is a 65 year old white male with a past medical history significant for an MI and depression who presents today complaining of sharp, epigastric abdominal pain of 3-4 months duration. The abdominal pain has been gradually worsening over the past 3-4 months. The pain has not changed or worsened acutely; Mr. H seeks care for the pain at this time because he is now covered by Medicare. The pain is located in the epigastric region and left upper quadrant of the abdomen. It does not radiate. The pain is relatively constant throughout the day and night but does vary in severity. Mr. H rates the pain as 6/10 at its worst. Mr. H describes the pain as a “sharp, burning” pain. He has not tried taking any medicines to relieve the pain. The pain is not alleviated with rest. Mr. H thinks the pain may be aggravated by throwing the football, but he has also experienced the pain independent of playing football or exerting himself. The pain is not associated with food or eating, although Mr. H does endorse occasional heartburn. Mr. H thinks the pain may at times be worse lying down, and it does wake him up at night. Mr. H denies any abdominal trauma or injury. He endorses a 5lb weight loss over the past 3-4 months, decreased appetite, and fatigue. He has experienced some drenching night sweats, requiring him to change his shirt but not his sheets. He describes a “lump in his throat” with associated dysphagia. He has experienced some nausea with the abdominal pain but has not vomited. He endorses constipation. He endorses bloody stools with some bowel movements. The blood is dark red in color and is not bright red. There is a sufficient amount of blood to turn the toilet water red. Mr. H does not know how many times per week he experiences this bleeding. He has not seen a bloody bowel movement in the past week.

Past Medical History

Other active health problems:
· Hypertension, diagnosed “years ago,” well-controlled with Metoprolol
· Depression, poorly controlled; started Prozac 6 months ago but still feels depressed
Hospitalizations: MI, 2004
Surgeries/procedures: Cardiac catheterization, post-MI, 2004

Medications

Aspirin 81mg po qd since his MI 3 years ago
Metoprolol 100mg po qd “for years”
Prozac 20mg po qd; Started 6 months ago
Protonix discontinued 12-18 months ago
Allergies: No Known Drug Allergies, no food or insect allergies

FH

Mother died at age 74 of “natural causes”; mother had HTN “for many years”
Father’s medical history not known
No known family history of colon cancer.

SH

Mr. H is a retired factory worker. He is divorced and has six children and one grandchild, whom he sees almost daily. Despite this, Mr. H says he still often feels alone, isolated, and depressed. He denies past or present tobacco and illicit drug use. He denies alcohol use. Mr. H does not have health insurance but is now covered by Medicare.
ROS
General – As indicated in the HPI, denies fevers or chills; endorses decreased appetite and a 5lb weight loss over the past 3-4 months; endorses fatigue
HEENT:
· Head – denies headache, dizziness, syncope
· Ears – denies difficulty or changes in his hearing, denies tinnitus
· Eyes – denies problems or changes in his vision; denies blurred vision; denies seeing spots
· Nose – Not assessed
· Throat – complains of a “lump in his throat;” endorses dysphagia
Cardiovascular – denies chest pain; denies palpitations
Pulmonary – denies shortness of breath, denies cough
Gastrointestinal – As indicated in the HPI, complains of sharp, epigastric abdominal pain; endorses constipation, denies diarrhea; endorses bloody stools
Genitourinary – denies dysuria; denies increased frequency or urgency of urination
Neurologic – denies numbness and tingling; denies paresthesias
Musculoskeletal – endorses abdominal pain occasionally after throwing the football; denies any muscle or joint pain
Endocrine – not assessed
Hematopoietic – denies easy bruising

Physical Exam

Vital signs: Ht. 5’10” Wt. 160lbs, BMI 28, HR 72, RR 16, BP 126/78, Temp 99.0
General: Mr. H is a depressed-appearing white male in no acute distress.
HEENT: Not examined
Lymph nodes: Non-tender, no palpable masses
Neck: No masses
Cardiovascular: Regular rate and rhythm; normal S1, S2; no murmurs, rubs, or gallops
Lungs: Lungs clear to auscultation bilaterally; No wheezes or crackles
Abdominal:
· Abdomen soft and non-distended with no scars or striations
· No pulsatile masses, no abdominal bruits auscultated
· Spleen not palpable, liver not palpable
· Tender to palpation in epigastric region and left upper quadrant; No reflex tenderness; No guarding; Murphy’s sign negative
Rectal: Hemoccult positive
Genitourinary: Not examined
Neurologic: Not examined
Musculoskeletal: Not examined
Laboratory Data: None collected
Diagnostic Tests: Hemoccult positive stool

Assessment:

1. Abdominal Pain
2. GI Bleed
3. Depression
4. Hypertension
Problem #1: Abdominal pain, bloody stools/GI Bleed
Differential diagnosis: colorectal adenocarcinoma, gastric ulcer, duodenal ulcer, GERD, intestinal obstruction, anxiety or depression related, abdominal aortic aneurysm, pancreatitis, pancreatic cancer
Diagnostic plan: Colonoscopy to evaluate the colon for presence of polyps or tumors
Therapeutic plan:
· If colon cancer is detected on colonoscopy, refer Mr. H to a GI oncologist.
· Restart Protonix therapy
· Treat constipation with laxative as needed or daily Metamucil
Patient Education: The importance of colonoscopy screening for colon cancer was discussed with the patient.
Problem #2: Depression
Therapeutic plan: Continue Prozac 20mg po qd for now. Consider switching to a different anti-depressant. Discuss counseling and therapy options.
Problem #3: Hypertension
Therapeutic plan: Continue Metoprolol 100mg po qd
Patient education: The importance of dietary salt and fat restriction and exercise were discussed with the patient
Follow up: Schedule appointment for return in 2 weeks.
Discussion and Logic for Diagnosis
(This is the argument for the decision making and actions taken; THIS IS NOT typically found in SOAP notes)
Given Mr. H’s age, history of bloody stools, Hemoccult positive stools on exam today, and the gravity of missing a cancer diagnosis, colorectal adenocarcinoma should be considered first in the differential. “Increasing age is probably the single most important risk factor for colorectal cancer in the general population. Risk increases steadily to age 50, after which it doubles with each decade” (Ruben, 608). Colon cancer is usually initially clinically silent and most commonly presents as hemoccult positive stools. However, large tumors can cause intestinal obstruction and associated constipation and abdominal pain. “A positive test result for fecal occult blood predicts the presence of a cancer or an adenoma in 50% of cases” (Ruben, 609). “Colon cancer is the second leading cause of cancer-related death in the United States” (American Cancer Society). However, if detected early and at a low stage, surgery can be curative.
Thus, at age 65, Mr. H is at risk for colorectal cancer. Furthermore, Mr. H’s bloody stools, hemoccult positive stool, weight loss, constipation, and abdominal pain are worrisome for cancer and possible intestinal obstruction by tumor. Therefore, based on this clinical presentation and the life-saving importance of early detection, Mr. H should first be evaluated for colon cancer by colonoscopy.
Gastric and duodenal ulcers can also cause epigastric abdominal pain and bloody stools, secondary to gastric bleeding. “The symptoms of gastric and duodenal ulcers are similar…[both are] characterized by epigastric pain 1 to 3 hours after a meal, or that awakens the patient at night” (Ruben, 567). Heartburn, nausea, and weight loss can also occur with gastric and duodenal ulcers.
Although Mr. H does not associate his abdominal pain with food or meals, his pain does wake him up at night. Furthermore, Mr. H’s abdominal pain onset 2 months after discontinuing Protonix, and he has experienced heartburn, nausea, bloody stools, and weight loss, all of which can be associated with gastric and duodenal ulcers. Therefore, gastric and duodenal ulcers should be considered next in the differential (Ruben, 567-568)
Gastroesophageal reflux disease (GERD) can also cause epigastric abdominal pain. Based on the onset of Mr. H’s abdominal pain 2 months after discontinuing Protonix, and his symptoms of a lump in his throat, dysphagia, heartburn, and nausea, GERD should be considered next in the differential (Ruben, 553-555).
Restarting Protonix therapy will decrease the amount of acid produced in Mr. H’s stomach and should alleviate symptoms resulting from gastric and duodenal ulcers and GERD. Therefore, if Mr. H’s abdominal pain is relieved with Protonix therapy; it can be attributed to one of these gastric-acid based conditions.
Finally, intestinal obstruction secondary to chronic constipation should be considered as a possible contributing factor to Mr. H’s abdominal pain. While such an obstruction could explain Mr. H’s pain, it does not explain his worrisome symptoms of bloody stools or the finding of Hemoccult positive stool and should therefore be considered in addition to another, more complete, explanation.
Similarly, anxiety or depression related abdominal pain, abdominal aortic aneurysm, pancreatitis, and pancreatic cancer would not explain Mr. H’s bleeding and, like intestinal obstruction, should only be considered in addition to another, more complete, explanation.

Sources

Rubin, R. and Strayer, D. Rubin’s Pathology. 5th edition. Lippincott Williams and Wilkins, 2008.
Source: http://www.kumc.edu/school-of-medicine/office-of-medical-education/clinical-skills-lab/student-tools/guidelines-for-soap.html
 
 
12 | SOAP NOTES

ADDITIONAL INSTRUCTIONS FOR THE CLASS

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• Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

• Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

• APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

• Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

• LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

• Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

• Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

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