NURS 7446/NURS 7556

AU/AUM SON Guidelines for SOAP Notes

Fall 2014

Label each section of the SOAP note

o (each body part and system)
Do not use unnecessary words or complete sentences
Use Standard/Universally accepted abbreviations
Search for and correct all spelling errors prior to submission

S: SUBJECTIVE DATA: (information the patient/caregiver tells you)

Introduction of the patient:
Name: 0410bc
Age: 9
Race: Caucasian
Gender: Male
Marital Status: Single
Historian: patient mother and patient
Chief Complaint (CC): Constipation
Pt presents with mother with complaints of constipation with left
lower quadrant abdominal pain, and abdominal cramping
intermittent
Mother reports patient normally has two small soft brown bowel
movements a day and 2 days ago one stool came out hard with
no pain reported and since patient has not had a bowel
movement despite sitting on the toilet to try.
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 ALL of these seven variables as it related to the CC/HPI
o Location: left lower quadrant pain, general abdominal
cramping
o Quality: describes pains as crampy and grabbing
describes no bowel movement in 2 days
o Severity: mother states patient has been able to go to
school but complaints about his stomach feeling full
o timing : symptoms onset times 2 days after completing
hard bowel movement. Pt denies any pain with bowel
movements.

setting: has bowel movements at home before and after

school
o alleviating and aggravating factors: states abdomen has
become more full with time and cramps are intermittent.
Aggravated by time alleviated with physical activity
(mother thinks when his mind is off of it)
o associated signs and symptoms: cramping / LLQ
abdominal pain diet not affected
Or an update on health status since the last patient encounter if
this is a follow-up visit for a previous acute or chronic visit.
o Pt has not had history of any bowel or urinary issues. Pt
had yearly exam at beginning of October and received
influenza vaccination by shot.
o

Past Medical History (PMH):

Update and list current medications (include name, dose,
frequency, and how long the patient has been on this
medication).
o Did the current medication replace a previous medication
prescribed to treat the same problem? If so, note why the
change.
o Note any problems with these medications (i.e. side
effects, price, patient understanding or compliance
issues)
o No current medications / no previous chronic medications
Allergies with patient response to the medication or other
allergen (latex, enviornmental).
o No known allergies noted. Patient has occasional seasonal
allergies but is not receiving treatment for these
Prior illnesses and injuries with dates of onset/occurrence,
previous or current treatments, and current (outcome) status of
these illnesses and/or injuries.
o No previous illness or injury noted
Date and name of previous operations
o No previous operations / pt was circumcised at birth
Description of previous hospitalizations, treatments and
outcomes.
o No previous hospitalizations
Documentation of age-appropriate immunization (vaccines) and
compliance with health promotion and health maintenance
guidelines as identified by the CDC and NIH (i.e. colonoscopy,
pap smears, mammograms, etc).
o Influenza given yearly and UTD
o Hepatitis B has received three step

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o
o
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Varicella vaccination 2 step

MMR 2 step
HIB given 3 step
DTaP as scheduled and UTD
IPV completed series
Hep A vaccination completed 2 step

Family History (FH):

Update significant medical information about the patient's family
(parents, siblings, and children).
o Mother: 32 Living (no known health problems)
o Father: 35 Living (HTN)
o Sister: 3 living no known health problems
Provide current age of parents, siblings, children; years with
disease; or age at death and cause of death.
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.
o Marital Status: single (mother is married and father lives
at home with mother)
o Living arrangements: lives with father, mother, and little
sister, stay with grandparents who live in town some
weekends
o Occupation: Student (currently in 3rd grade, enjoys school)
o Negative Drug Use, No consumption of alcohol
o Smoking: no family members in the home or grandparents
smoke, not typically exposed to smoke
o Education: currently in 3rd grade (participated in local
head start)
o Not sexually active
o Plays little league football
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 are new or have
occurred since last visit;
o (1) constitutional symptoms (e.g., fever, weight loss), pt

active in the room upon exam. pt interacts with clinician and

o
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mother. Pt follows commands and is attentive. Pt has had no fever

or weight loss, shortness of breath or chest pain.
(2) eyes, normal eye exam history x1 visit and normal snellen at
school denies any symptoms of double or blurred vision. No
redness noted
(3) ears, nose, mouth and throat, Ears: hearing acuity normal,
denies pain to ears, Nose: Sense of smell intact, no deviation in
septum, denies sinus congestion or epistaxis. Mouth:, teeth appear
normal and intact, mucous membranes moist and pink. Pt mother
reports child brushes teeth at morning and at night. Normal dental
exams. Pt has lost some baby teeth but still has some baby teeth
per mother. Throat: no sore throat reported, no odor noted, No
redness noted
(4) cardiovascular, Reports no chest pain or palpitations no
activity intolerance
(5) respiratory, negative cough; negative shortness of breath,
negative recent fever or chest congestion, negative exposure to
smoke, negative history of asthma or respiratory disease
(6) gastrointestinal, positive abdominal pain (LLQ),
negative nausea, negative vomiting, positive constipation,
negative blood in stool, negative tenderness to abdomen,
positive cramping (not visualized) No stool leakage noted,
no rectal discomfort reported, pt has no history of bowel
problems
(7) genitourinary, Denies urinary symptoms of nocturia, dysura,

incontinence.
o

(8) musculoskeletal, negative scoliosis screenings yearly,

denies any joint stiffness, denies muscle pain, denies
history of fracture or advanced sprain / strain
(9) integument (skin and/or breast), skin is normal for
race, no abnormal lesions noted, skin turgor normal, no
bruising noted,
(10) neurological, no fatigue or muscle weakness, negative,

syncopy, negative hx of seizure, loss of memory, or severe

headaches. No history of hard hits to head in football or ever
having concussion symptoms
o
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(11) psychiatric, negative anxiety, negative mood swings,

negative psych history
(12) endocrine, negative heat or cold intolerance,
negative sleep disturbance,
(13) hematological/lymphatic, denies unusual bruising,

bleeding, transfusion history, reports no fatigue or weakness

(14) allergic/immunologic, Denies any food allergies, some

seasonal allergies (possibly goldenrod), no known medication

allergies as listed above
*Refer to the Medatrax comprehensive SOAP guidelines for detail/system.
O: OBJECTIVE DATA: (information you observe with your senses, lab
results, and/or chart notes)

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.
Detailed assessment of system(s) that are impacted by CC/HPI.
o Record observations for the following systems if
applicable to this patient encounter (there are 12 systems
for examination):
o (1) Constitutional (e.g. vita! signs, general appearance),
Vitals: Temp: 98.5 BP: deferred Pulse: 86 O2: 99%RA RR:
22 Pain: 2/10 current faces Ht: 52 Wt: 69 BMI 17.9,
General Appearance is fair, pt awake and alert and
answers questions. Pt makes good eye contact and
follows commands.
o (2) Eyes, no redness noted, pupils equal and reactive to light,

conjuctiva are nomal, no jaundice noted. No drainage noted.

o

(3) ENT/mouth, EARS, tm grey with no evidence of

infection, no bulging noted, no redness to canals,
moderate amount of cerumen EYES, pupils equal and

reactive to light, conjuctiva are nomal, no jaundice noted. No

drainage noted, visual acuity normal without corrective lesnses.
NOSE, no drainage from nose, nostrils patent, MOUTH, dentition
normal, mucous membranes moist / pink, lips moist, and gums
normal with no lesions, uvula midline, no odor from mouth, No
exudates noted to back of throat. Tongue is midline and of normal
size.
o (4) Cardiovascular, Heart Sounds Normal S1, S2, no murmurs,
clicks, gallops, Peripheral pulses intact, no edema noted
o (5) Respiratory No Cough noted, respiratory effort is unlabored
and regular, lung sounds clear bilaterally, No sputum noted
o

(6) GI, bowel sounds active throughout, no masses noted,

liver tail palpable with no nodule noted, abdomen is soft, ,
no abdominal tenderness noted, palpable large intestine
with no tenderness upon palpation, bowels feel full to
ascending colon. no blood noted per patient.

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(7) GU, pt denies any dysuria or genitourinary concerns,

(8) Musculoskeletal, no bony abnormality noted. Pt denies any

pain to extremeties, back, pelvic cage., pt negative scoliosis

screening at yearly exam. gait normal.
o (9) Skin, normal color for race, no lesions noted to visible
fields, no rash noted, skin is warm and dry with good skin turgor,
no skin dryness noted, no breakdown in skin noted.
o (10) Neurological, pt alert and oriented x3. No decrease in
sensation noted, reflexes intact bilaterally No gross neurological
abnormalities noted on exam.
o

(11) Psychiatric, no history of psychiatric disorder. Pt

makes good eye contact and communicates needs. Pt
talks about enjoyed activites such as football
(12) Hematological/lymphatic/immunologic. no evidence of

bruising or bleeding, no jaundice noted., no report of fever, no

reported lymphadenopathy, denies blood in stool.
o (13) Developmental: Child shows interest in school activities and
sports, enjoys going to friends birthday parties, on track in
schooling and makes As with occasional B.

NOTE: Cardiovascular and Respiratory systems should be

assessed on every patient regardless of the chief complaint.

If is not appropriate to assess each system note that it was

not assessed and why.
Results of any diagnostic or lab testing ordered during that
patient visit. Note results if available or pending.

A: ASSESSMENT / ANALYSIS:
Determine and list the Level of the visit based on the CPT
documentation criteria (separate handout, in Medatrax, and
probably available in clinic)
o Level of Visit 99214
List and number in PRIORITY order the possible diagnoses
(problems) you have identified.
o 1. 564.0 Constipation (most likely)
o 2. 560.3 Impaction of intestine
o 3. 197.5 Large intesting and rectum (neoplasm)
Identify the ICD-9 code for each diagnosis
o Identify any procedure codes if appropriate

These diagnoses are the conclusions you have drawn from the
subjective and objective data.

Remember: Your 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 (symptoms, probable diagnoses) of patient
problems in the following areas if applicable:
1. Acute Self-Limited Problems
1. Constipation
Constipation is the primary and final diagnosis. In cases of
impaction with the abdominal distention I would expect
far worse pain and stool leakage. When asking the mother
if the child had any foot support while having bowel
movements she stated he had not. Also with the
explanation of small stools twice a day the patient could
not be completely emptying his lower bowel with each
bowel movement.
In cases where the diagnosis is already made (follow-up
visits/referrals), state that it is "improved, well-controlled,
resolving or resolved" or that it is "now inadequately controlled,
worsening or failing to change as expected"

P: PLAN / INTERVENTION / MANAGMENT

Number the interventions to correlate with the diagnoses in the
assessment/analysis section.
Interventions include a number of tests and referrals
To further nail down diagnosis many interventions will take place
o 1,3 KUB
o 1,2, Digital rectal exam: this was not completed in clinic
but would be more necessary if child having leakage.
List actions planned to manage each problem.
o For medications ordered select ONLY (1) medication and
provided detailed information related to: Miralax
Indication for this patient: to treat constipation,
softening stools
MOA (brief) osmotic laxative: causes water
retention in stool, causing increase in frequency
Usual dosage: 0/5-1.5g/kg PO once daily for no
longer than 2 weeks
Available as name brand, generic or both: available
as both
Cost out the medication at 3 different pharmacies

Other
o
o
o

List the names of the 3 pharmacies

contacted
Target: $9.49
Walmart: $9.48
CVS $12.99
Cost of prescription at each pharmacy as
prescribed
o Chronic condition - note the cost for a
30 day supply.
interventions to include:
Outside diagnostic test procedures ordered and why
KUB as noted above
Follow-up
Pt to report to clinic or ER if development of fever,
pain worsening, or change in location, or any
concerns
Pt to report in 10 days for evaluation of action plan
and modification as necessary.
Consultation/Referrals (if applicable)
Refer to Gastroenterology if no improvement at
follow-up
Patient education needs (identify all that apply)
Current treatment plan
Begin Miralax 17g daily for 4-5 days
Increase in fluid intake
Fiber 10-15grams per day in diet
Provide support to feet while having bowel
movement (suggest mother place hands
under childs feet or place books under the
feet to give support so the patient can have
a full bowel movement.
Health promotion- Consume a well balanced diet
with a mixture of meat, fruits, vegetables and
grains, Increase fiber in diet, continue getting good
exercise even when not in football season,
encourage adequate hydration with sports and to
promote bowel health encourage plenty of rest at
least 10-11 hours a night
Health maintenance- annual eye exam, Annual
dental exam, continue regular yearly follow-ups
after acute problems. Continue Immunizations as
scheduled,
Disease prevention: Influenza yearly, obesity
screenings, scoliosis screening per school and at
yearly visits.

Other interventions that are specific to your patient but not

listed above.