NU 611 Unit 7: Comprehensive SOAP Notes

S: SUBJECTIVE DATA
CC:	“I have been having hot flashes and trouble sleeping for the past few months.”
HPI:	M.T., an African American woman, is 49 years old and has had hot flashes and trouble sleeping for 6 months. According to her, the symptoms started mild and have steadily become more severe over the course of time. She remembers a quick sensation of heat that swept across her chest, neck, and face. According to her, each episode lasts between two and five minutes and occurs between five and seven times every day, most frequently throughout the night. She also has flushing, sweating, and palpitations on occasion as a result of this condition. The factors that she cites as triggers are things like stress, hot settings, caffeine, and spicy foods. Fans and removing layers of clothing are two of the cooling tactics that she finds to be helpful in providing some relief. Even though M.T. has not utilized any prescription medications, she has attempted to alleviate her symptoms with herbal supplements that are available without a prescription. The symptoms, which she defines as moderate to severe, interfere with her ability to sleep and function daily. Although she has had vaginal dryness, decreased libido, and irregular menstrual cycles during the previous year, she has denied any chest pain, weight loss, or fever.
PMH:	Hypertension, which was identified five years ago Hyperlipidemia Don't use plagiarized sources. Get Your Custom Essay on NU 611 Unit 7: Comprehensive SOAP Notes Just from $7/Page Order Essay No hospitalizations in the ten years before this Surgical history: Tubal ligation at age 32
ALLERGIES	NKDA
MEDICATIONS	Lisinopril 10 mgs orally once daily (hypertension) A nightly dose of 20 mgs of atorvastatin orally (hyperlipidemia) A multivitamin daily and an occasional over-the-counter black cohosh supplement
SH	Occupation: Office administrator Living situation: Resides with a spouse Tobacco: Denies Alcohol: Occasionally (one or two drinks per week) Recreational drugs: Denies Diet: Moderate, reports consuming two to three cups of caffeine daily. Exercise: One or two walks every week Sexual activity: Vaginal dryness is reported; active with spouse Stress: Moderate stress (related to employment) Sleep: Due to night sweats, sleep is poor (4–5 hours/night). Financial resources: Stable, insured
FH	Mother: hypertension and menopause at age 50 Father: passed away at age 68 (MI) Maternal grandmother: Osteoporosis No history of breast or ovarian cancer in the family
HEALTH PROMOTION & MAINTENANCE	All vaccinations are current, including those for influenza, COVID booster, and Tdap. Mammogram: The most recent one was performed one year ago (normal). A normal Pap smear was performed two years ago. Currently, the screening for colon cancer has not been performed (recommended). Diet: There is room for improvement (high caffeine content). Physical activity: less than the prescribed 150 minutes per week Examined by the dentist six months ago Exam of the eyes: one year ago
ROS (Put N/A in sections not completed on the day of the exam.)	Constitutional	Reports tiredness, denies fever or weight reduction
	Head	Denies the presence of headaches
	Eyes	Denies alterations in vision
	Ears, Nose, Mouth, Throat	Denies nasal congestion or pharyngitis
	Neck	Denies rigidity
	Cardiovascular/Peripheral Vascular	Intermittent palpitations during hot flashes; denies experiencing chest pain.
	Respiratory	Denies shortness of breath or cough
	Breast	Denies the presence of lumps or discharge
	Gastrointestinal	Denies the presence of nausea, vomiting, or stomach discomfort
	Genitourinary	Reports irregular menstruation and vaginal dryness; denies dysuria.
	Musculoskeletal	Denies the presence of joint discomfort
	Integumentary	Reports of flushing during hot flashes; no rash observed.
	Neurological	Denies vertigo or fainting
	Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)	Exhibits irritability and sleep disturbances; PHQ-9 score: 6 (moderate depression)
	Endocrine	Reports intolerance to heat; denies intolerance to cold.
	Hematologic/Lymphatic	Denies the presence of bruises or lymphadenopathy
	Allergic/Immunologic	None
	Other	N/A

O: OBJECTIVE DATA
VITALS:	HR: 82 bpm	RR: 16	BP: 128/78 mmHg		Temp: 98.6°F
	SpO₂: 98% RA	Ht: 5’4”	Wt.: 165 lb.		BMI: 28.3
	Age: 49	LMP: 02/10/2026	Pain: 0/10
PHYSICAL EXAM (Pertinent data related to the presenting problem or visit type. Put N/A in sections not completed on the day of the exam.	General Appearance			Alert, well-nourished female, with no severe discomfort
	Head			Normocephalic and atraumatic
	Eyes			EOMI, PERRLA
	ENT, Mouth			Moist mucous membranes
	Neck			Absence of lymphadenopathy or thyromegaly
	Cardiovascular/Peripheral Vascular			No murmuring, regular rhythm and pace
	Respiratory			Both sides are clear to auscultation.
	Breast			Absence of discharge, soreness, or masses
	Gastrointestinal			Non-tender, soft, and free of organomegaly
	Genitourinary Male
	· External Exam			N/A
	· Internal Exam			N/A
	Genitourinary Female
	· External Exam			There was some mild vaginal dryness.
	· Internal Exam			Deferred
	Musculoskeletal			No soreness, normal range of motion
	Integumentary			Warm and free of lesions
	Neurological			x3 alert and focused, no deficiencies
	Psychiatric			Appropriate affect and mood
	Endocrine			There is no enlargement of the thyroid.
	Hematologic/Lymphatic			No lymphadenopathy or bleeding was present.
	Allergic/Immunologic			None
	Other			None

A: ASSESSMENT AND DIAGNOSIS
	DIAGNOSIS	ICD-10 CODES
PRIORITIZE DIAGNOSIS	1. Menopausal and female climacteric states (vasomotor symptoms)	N95.1
	2. Insomnia, unspecified	G47.00
	3. Encounter for general adult medical examination with abnormal findings	Z00.01

VISIT CODES

CPT BILLING CODES

99214 (Established patient, moderate complexity)

DIAGNOSTICS

POC TESTING

None performed today

TESTS REVIEWED

· To rule out the possibility of thyroid malfunction, TSH is needed

· A measurement of the levels of FSH and estradiol (to support menopausal status if it is required)

· Regular monitoring of the lipid panel

· CMP (Lee et al., 2022).

P: PLAN
ACTIONS	1.	Diagnosis: Menopausal Vasomotor Symptoms Diagnostics: Labs as listed above Therapeutic: Paroxetine 7.5 mg orally twice daily, 30 milligrams, with two refills (a non-hormonal treatment for hot flashes) should be started (Lee et al., 2022). If symptoms continue to be present and there are no contraindications, hormone replacement therapy (HRT) may be an option. Education: Caffeine, spicy foods, and the presence of hot settings should be avoided. Wear layers, and keep the temperature at a cool level. Foster healthy weight management and consistent physical activity. The risks and advantages of hormone replacement therapy Consultation/Collaboration: Consider referring the patient to gynecology for an examination of hormone replacement therapy (HRT) if the symptoms become more severe (Khan et al., 2023).
	2.	Diagnosis: Insomnia Diagnostics: There is no urgent testing necessary for the sleep exam. Therapeutic: Melatonin 3 mg orally nightly, as needed, dose #30, one refill Counseling on proper sleep hygiene Education: Continue to adhere to a regular sleep pattern. Avoid using electronic devices before going to bed. Avoid consuming too much caffeine, especially in the afternoon. Consultation: If insomnia is persistent, behavioral therapy should be considered (Paul et al., 2022).
	3.	Diagnosis: Preventive Care with Abnormal Findings Diagnostics: The referral for a colonoscopy (screening that is age-appropriate) Typical laboratory tests, as described above Therapeutic: Lisinopril and Atorvastatin should be continued. Education: Perform more physical activities (at least 150 minutes per week). Balanced food, and lesser caffeine intake Maintain yearly checkups (mammogram, Pap smear) Consultation: Referral for colon and cervical cancer screening (Long et al., 2023).
PREVENTIVE (Used for comprehensive exams)	· Encourage consistent physical activity and healthy weight control. · Consuming calcium and vitamin D is beneficial to bone health. · Tobacco abstinence and moderate consumption of alcohol · Techniques for the control of stress · Education regarding the menopause and the management of symptoms · The counseling of osteoporosis prevention and fall risk protection is important (Kiran et al., 2022).
FOLLOW UP	· Follow-up in six to eight weeks to assess the degree of symptom improvement · The patient is advised to come back sooner if the symptoms become more severe or if new symptoms appear. · The annual checkup for health is recommended · Lab results will be reviewed during the next visit

References

Khan, S. J., Kapoor, E., Faubion, S. S., & Kling, J. M. (2023). Vasomotor Symptoms During Menopause: A Practical Guide on Current Treatments and Future Perspectives. Taylor & Francis. https://www.tandfonline.com/doi/full/10.2147/IJWH.S365808

Kiran, A., Schultz, N. M., Siddiqui, E., Todorova, L., Van Der Poel, B., Stoelzel, M., & Robinson, L. (2022). Epidemiology and treatment patterns of UK women diagnosed with vasomotor symptoms: Findings from the Clinical Practice Research Datalink GOLD database. Maturitas, 164, 1–8. https://doi.org/10.1016/j.maturitas.2022.05.013

Lee, E., Anselmo, M., Tahsin, C. T., Vanden Noven, M., Stokes, W., Carter, J. R., & Keller-Ross, M. L. (2022). Vasomotor symptoms of menopause, autonomic dysfunction, and cardiovascular disease. American Journal of Physiology-Heart and Circulatory Physiology, 323(6), H1270–H1280. https://doi.org/10.1152/ajpheart.00477.2022

Long, M. E., Lee, Y. S., & Vegunta, S. (2023). Cervical cancer screening in menopause: when is it safe to exit? Menopause, the Journal of the North American Menopause Society, 30(9), 972–979. https://doi.org/10.1097/gme.0000000000002222

Paul, S., Vidusha, K., Thilagar, S., Lakshmanan, D. K., Ravichandran, G., & Arunachalam, A. (2022). Advancements in the contemporary clinical diagnosis and treatment strategies of insomnia disorder. Sleep Medicine, 91, 124–140. https://doi.org/10.1016/j.sleep.2022.02.018

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Comprehensive SOAP Note

Instructions

Over the course of the semester you will choose 1 patient encounter each week to document a SOAP note for. In Weeks 5, 6, and 7, you will submit a full SOAP note for your chosen encounter.

It is expected that you vary the primary focus of each note to ensure you are receiving quality feedback for several types of patient encounters to include acute, chronic and wellness encounters. You are not to utilize the same type of encounter, acute/chronic health condition or wellness exam, more than once unless you have received approval to do so from your clinical faculty person.

SOAP notes will be evaluated using a standardized rubric. Please review the evaluation criterion to ensure that your SOAP notes are constructed to address the required elements and desired level of achievement.

For planned weekly clinical experiences submission of the SOAP notes would be accomplished by submitting one SOAP note weekly for weeks 2 through week 7.

For planned and approved condensed, compressed or alternate clinical experiences, submission of the SOAP note would be dependent on the approved clinical schedule. This may mean that more than 1 SOAP note would need to be submitted on a weekly basis. If you are not in clinical for weeks where a SOAP note is due a ‘0’ will be input into the Grade Center as a place holder until you have submitted the required assignment.

Complete this assignment and submit it to this assignment dropbox by Sunday at 11:59 pm CT.

Estimated time to complete: 1 hour

Assignment Resources

SOAP Note Template Download SOAP Note Template

Rubric

NU611 Unit 7 Assignment – SOAP Note Evaluation Rubric

NU611 Unit 7 Assignment – SOAP Note Evaluation Rubric
Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomeICD-10 Code	4.2 ptsHighly ProficientICD-10 Code provided with appropriate modifiers congruent with the clinical information provided 2.52 ptsMarginally ProficientICD-10 Code provided with limited clinical information detail 0.84 ptsNot ProficientICD-10 code provided is not congruent with the clinical information provided 0 ptsNot evidentICD-10 Code not provided	4.2 pts
This criterion is linked to a Learning OutcomeE&M CPT Code	4.2 ptsHighly ProficientClinical information provided is congruent with and supports the CPT Code identified in the encounter 2.52 ptsMarginally ProficientClinical information provided is either not congruent with or does not support the CPT Code identified in the encounter 0.84 ptsNot ProficientClinical information provided is not congruent with and does not support the CPT Code identified in the encounter 0 ptsNot evidentCPT Code not provided	4.2 pts
This criterion is linked to a Learning OutcomeSubjective Data	12.5 ptsHighly ProficientElements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are adeptly documented and demonstrate consistent information across all aspects represented 10 ptsProficientElements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are appropriately documented and demonstrate consistent information across all aspects represented 7.5 ptsMarginally ProficientElements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are satisfactorily documented but do not demonstrate consistent information across all aspects represented 5 ptsApproaching ProficiencyElements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are either not satisfactorily documented or do not demonstrate consistent information across all aspects represented 2.5 ptsNot ProficientElements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are not satisfactorily documented and do not demonstrate consistent information across all aspects represented 0 ptsNot evidentThere are elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) that are not provided in the assignment	12.5 pts
This criterion is linked to a Learning OutcomeObjective Data	12.5 ptsHighly ProficientElements of objective data are adeptly documented and demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS 10 ptsProficientElements of objective data are appropriately documented and demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS 7.5 ptsMarginally ProficientElements of objective data are satisfactorily documented but do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS 5 ptsApproaching ProficiencyElements of objective data are either not satisfactorily documented or do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS 2.5 ptsNot ProficientElements of objective data are not satisfactorily documented and do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS 0 ptsNot evidentThere are elements of objective data that are not provided in the assignment	12.5 pts
This criterion is linked to a Learning OutcomeAssessment	8.3 ptsHighly ProficientAssessment designations and other elements in this section are adeptly documented and demonstrate congruence with information documented in the CC, HPI, PMH, ROS, and the objective data 6.64 ptsProficientAssessment designations and other elements in this section are appropriately documented and demonstrate congruence with information documented in the CC, HPI, PMH, ROS, and the objective data 4.98 ptsMarginally ProficientAssessment designations and other elements in this section are satisfactorily documented but do not demonstrate congruence with information documented in the CC, HPI, PMH, ROS, and the objective data 3.32 ptsApproaching ProficiencyAssessment designations and other elements in this section are either not satisfactorily documented or do not demonstrate congruence of information documented in the CC, HPI, PMH, ROS, and the objective data 1.66 ptsNot ProficientAssessment designations and other elements in this section are not satisfactorily documented and do not demonstrate congruence of information documented in the CC, HPI, PMH, ROS, and the objective data 0 ptsNot evidentAssessment designations and other elements in this section are not provided in the assignment	8.3 pts
This criterion is linked to a Learning OutcomePlan	8.3 ptsHighly ProficientElements of the plan are adeptly documented, demonstrate application of current clinical practices for the identified assessment designations, and demonstrate congruence of information across all aspects represented 6.64 ptsProficientElements of the plan are appropriately documented, demonstrate application of current clinical practices for the identified assessment designations, and demonstrate congruence of information across all aspects represented 4.98 ptsMarginally ProficientElements of the plan are satisfactorily documented but either do not demonstrate application of current clinical practices for the identified assessment designations, or do not demonstrate congruence of information across all aspects represented 3.32 ptsApproaching ProficiencyElements of the plan are either not satisfactorily documented, or do not demonstrate application of current clinical practices for the identified assessment designations, or do not demonstrate congruence of information across all aspects represented 1.66 ptsNot ProficientElements of the plan are not satisfactorily documented, do not demonstrate application of current clinical practices for the identified assessment designations, and do not demonstrate congruence of information across all aspects represented 0 ptsNot evidentElements of a plan are not provided in the assignment	8.3 pts

Total Points: 50