Wellness SOAP note

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Wellness SOAP note

Please help creating a Wellness SOAP note with a hypothetical patient.

ENSURE TO COVER ALL POINTS INCLUDING A FEASIBLE HX

FOLLOW APA STYLE REFERENCING

REFER TO THE RUBRIC AND THE SAMPLE ATTACHED IN FILES

Grading Rubric

Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1)
Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

2)
Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

3)
Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b) Pertinent positives and negatives must be documented for each relevant system.

c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4)
Assessment (___10pts.): Encounter paragraph and diagnoses should be clearly listed and worded appropriately including ICD10 codes.

5)
Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

6)
Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

7)
Clarity of the Write-up(___5pts.): Is

Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C

Soap Note # ____ Main Diagnosis: Z00.01-Annual Wellness Check up PATIENT INFORMATION

Name S.N.
Age: 55 yrs
Gender at Birth: Male
Gender Identity: Male
Source: Patient
Allergies: Denies food, environmental, or drug allergy
Current Medications: Denies use of medications. Takes no herbal medicines or supplement medicatio ns.
PMH: He has no history of hospitalizations. Denies chronic illnesses such as cancer, HTN, psychiatric diseases, asthma, or diabetes.
Immunizations: COVID 19 vaccine on 10/12/2021. He received the influenza vaccine on 5/2021. Tdap booster was given in 2010. He received all childhood immunizations but was unable to recall the exact dates.
Preventive Care: RBS done on 20/3/2021. B.P. measurements taken on 20/3/2021
Surgical History: No history of recent or previous surgeries.

1

Family History: Raised by biological parents. His mother is 78years and has HTN and diabetes. Father is 85 years with no chronic illness. His maternal grandfather died at 80 years and had a history of BPH and HTN.
Social History: He is a small-scale farmer. Married to one wife.Has three children. He neither smokes nor drinks.

Sexual Orientation: He has one wife, and he is heterosexual
Nutrition History: He takes a balanced diet. He avoids fat-rich diets and processed foods. He takes a fruit every day in the morning. He drinks seven glasses of water every day. He does not drink sweetened drinks or coffee.

Subjective Data:
Chief Complaint: “I am feeling great, but I am here for my annual check-up.”
Symptom analysis/HPI: The patient’s last annual check-up was in May 2021. The patient reports the absence of any abnormal laboratory or physical findings during that check-up. His previous eye examination was on October 2021. His last dental review was in November 2021. Colonoscopy and PSA test were done in January 2018. His previous B.P. screening, Blood Sugar Screening were done in March 2021. Lip profile tests were done in January 2017. There were no other current concerns or complaints by the patient.
Review of Systems (ROS
CONSTITUTIONAL: No fatigue, chills, general body weakness, night sweats, or fever RESPIRATORY: No dyspnea, wheezing, chest pains, or cough
GASTROINTESTINAL: No nausea, abdominal pain, vomiting, or diarrhea

2


NEUROLOGIC: No numbness, loss of consciousness, tingling, or confusion
HEENT: H: no dizziness, headache, or confusion. Eyes: no itching, pain, diplopia, or blurry vision Ears: no pain, hearing loss, tingling sensation, or discharges Nose: No bleeding, itching, or discharge o Throat: no sore throat, edema, or voice changes
CARDIOVASCULAR:

Wellness SOAP note Please help creating a Wellness SOAP note with a hypothetical patient. ENSURE TO COVER ALL POINTS INCLUDING A FEASIBLE HX FOLLOW APA STYLE REFERENCING REFER TO THE RUBRIC AND THE SAMPLE ATTACHED IN FILES Grading Rubric Student______________________________________ This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up. 1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number. 2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following: a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts). b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts). c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner. 3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate. a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts). b) Pertinent positives and negatives must be documented for each relevant system. c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts). 4) Assessment (___10pts.): Encounter paragraph and diagnoses should be clearly listed and worded appropriately including ICD10 codes. 5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections. 6) Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified. 7) Clarity of the Write-up(___5pts.): Is Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C Soap Note # ____ Main Diagnosis: Z00.01-Annual Wellness Check up PATIENT INFORMATION Name S.N. Age: 55 yrs Gender at Birth: Male Gender Identity: Male Source: Patient Allergies: Denies food, environmental, or drug allergy Current Medications: Denies use of medications. Takes no herbal medicines or supplement medicatio ns. PMH: He has no history of hospitalizations. Denies chronic illnesses such as cancer, HTN, psychiatric diseases, asthma, or diabetes. Immunizations: COVID 19 vaccine on 10/12/2021. He received the influenza vaccine on 5/2021. Tdap booster was given in 2010. He received all childhood immunizations but was unable to recall the exact dates. Preventive Care: RBS done on 20/3/2021. B.P. measurements taken on 20/3/2021 Surgical History: No history of recent or previous surgeries. 1 Family History: Raised by biological parents. His mother is 78years and has HTN and diabetes. Father is 85 years with no chronic illness. His maternal grandfather died at 80 years and had a history of BPH and HTN. Social History: He is a small-scale farmer. Married to one wife.Has three children. He neither smokes nor drinks. Sexual Orientation: He has one wife, and he is heterosexual Nutrition History: He takes a balanced diet. He avoids fat-rich diets and processed foods. He takes a fruit every day in the morning. He drinks seven glasses of water every day. He does not drink sweetened drinks or coffee. Subjective Data: Chief Complaint: “I am feeling great, but I am here for my annual check-up.” Symptom analysis/HPI: The patient’s last annual check-up was in May 2021. The patient reports the absence of any abnormal laboratory or physical findings during that check-up. His previous eye examination was on October 2021. His last dental review was in November 2021. Colonoscopy and PSA test were done in January 2018. His previous B.P. screening, Blood Sugar Screening were done in March 2021. Lip profile tests were done in January 2017. There were no other current concerns or complaints by the patient. Review of Systems (ROS CONSTITUTIONAL: No fatigue, chills, general body weakness, night sweats, or fever RESPIRATORY: No dyspnea, wheezing, chest pains, or cough GASTROINTESTINAL: No nausea, abdominal pain, vomiting, or diarrhea 2 NEUROLOGIC: No numbness, loss of consciousness, tingling, or confusion HEENT: H: no dizziness, headache, or confusion. Eyes: no itching, pain, diplopia, or blurry vision Ears: no pain, hearing loss, tingling sensation, or discharges Nose: No bleeding, itching, or discharge o Throat: no sore throat, edema, or voice changes CARDIOVASCULAR:

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