Nursing Soap note

CC: Reason given by the patient for seeking medical care “in quotes”. Select ONE complaint that you will investigate for this note. Do NOT select a routine follow-up exam, or a scheduled annual physical. 
HPI: Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness. 
Medications: (list with reason for med ) 
PMHAllergies:   Medication Intolerances: Chronic Illnesses/Major traumas Hospitalizations/Surgeries 
Family HistoryDoes your mother, father or siblings have any medical or psychiatric illnesses?  Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease. 
Social HistoryEducation level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana.  Safety status 
GeneralWeight change, fatigue, fever, chills, night sweats,  energy level CardiovascularChest pain, palpitations, PND, orthopnea, edema 
SkinDelayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or molesRespiratoryCough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB 
EyesCorrective lenses, blurring, visual changes of any kind GastrointestinalAbdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools 
EarsEar pain, hearing loss, ringing in ears, discharge Genitourinary/GynecologicalUrgency, frequency burning, change in color of urine.Contraception, sexual activity, STDS   Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx  Male: prostate, PSA, urinary complaints 
Nose/Mouth/ThroatSinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain MusculoskeletalBack pain, joint swelling, stiffness or pain, fracture hx, osteoporosis
BreastSBE, lumps, bumps or changesNeurologicalSyncope, seizures, transient paralysis, weakness, paresthesias, black out spells
Heme/Lymph/Endo HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerancePsychiatric Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx
Weight        BMITempBP
General AppearanceHealthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later.
SkinSkin is brown, warm, dry, clean and intact. No rashes or lesions noted.
HEENTHead is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.
CardiovascularS1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.
RespiratorySymmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
GastrointestinalAbdomen obese; BS in all 4 quadrants; you must designate whether the BS are normoactive, hyper, or hypo. Abdomen soft, non-tender. No hepatosplenomegaly
BreastBreast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.
GenitourinaryBladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.  No adnexal masses or tenderness. Ovaries are non-palpable.(Male:  both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )(Rectal as appropriate:  no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).
MusculoskeletalFull ROM seen in all 4 extremities as patient moved about the exam room.
NeurologicalSpeech clear. Good tone. Posture erect. Balance stable; gait normal.
PsychiatricAlert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.
Lab TestsUrinalysis – pendingUrine culture – pendingWet prep – pending 
Special Tests 
 Differential Diagnoses – List at least three possible diagnoses for the chief complaint. This is NOT a list of unrelated, multiple diagnoses the patient may have. Focus on the chief complaint.You must include the rationales for why you are considering each differential as a possibility for this patient. Plan on two to three sentences for each differential diagnosis listed.· 1-· 2-· 3-Diagnosis – You must include how you arrived at this diagnosis. What was your thinking? You must convince me you are on the right path.
· Plan:  Be specific to this patient and include the following as applicable.· Further testing· Medication· Education· Non-medication treatments· Return to clinic· Referrals
 Evaluation of patient encounter – The following are required components to this section of the note:1. Self-Assessment: Answer each of the following questions:—Was the plan of care evidence-based? How? Convince me why you are doing what you are doing.—What did you learn? Be specific.—Would you have changed anything in the encounter? Why or why not?2. References to support your treatment plan – must be current and in the reference style as though you were writing a paper.

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