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Academic SOAP Note Template
Reason for Follow-Up: A one-sentence description of the primary working diagnosis that
identifies admit date or hospital day of visit, pending differential diagnoses, and context or
service in which the patient is being seen is provided and includes supporting details.
Clinical Course Summary: A one-to-two paragraph description of the current illness or hospital
stay, including pertinent diagnostic findings or procedures and the number of days since the
patient has been hospitalized, is complete with supporting documentation. (This is not the HPI.)
Review of systems: Review of the symptoms the patient or his/her family explains, organized by
system. Five systems affected by the working diagnosis, along with two positive or negative
effects of the diagnosis on each system, are provided with thorough details and support. Refer to
the H&P template for ROS options.
Physical Exam: Five systems examined within the last 24 hours, including two positive or
negative findings relevant to each system and a full set of vital signs, are provided with thorough
details and support. Refer to the H&P template for ROS options.
Laboratory and Radiology Results: List pertinent data available when seeing the patient
pertinent to the reasons for follow-up. Include normal and abnormal results and identify the
abnormalities.
Assessment: (Provide three references) Identification of all acute and chronic diagnoses in
order of ICD-10 priority and any differential diagnoses being eliminated are provided with
thorough details and support.
Differential diagnoses: What is pending to be ruled in or
ruled out? A differential is only
needed if there is a sign/symptom for which you have not
identified a diagnosis.
Acute and chronic medical conditions: Include the ICD-10
diagnosis code (look in
Lopes Activity Tracker).
Treatment Plan: (Provide three references) A treatment plan that corresponds with the
diagnosis and includes admission type, diagnostics, medications and dosages, and any consults
or follow-up procedures needed is provided with thorough details and support.
What orders are you starting? What medications (include dose and frequency of new meds or
changes in dose of existing meds)? What consults? Education topics? Discharge plan?
Geriatric Considerations: Based on the age, address any differences in the treatment if the
patient were younger or older.
References: Use three references listed in APA format.
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Academic Clinical History and Physical Note – Rubric
Collapse All Academic Clinical History And Physical Note – RubricCollapse All
History and Physical Note
10 points
Criteria Description
History and Physical Note (Chief Complaint, HPI, Patient History, Home Medications, Review of Systems, Vital Signs, Physical Exam, Test Results)
5. Target
10 points
The history and physical note is thoroughly explored and clearly explained with relevant details and support.
4. Acceptable
9 points
The history and physical note is provided with appropriate details and support.
3. Approaching
8 points
The history and physical note is present, but only minimal detail or support is provided.
2. Insufficient
5 points
The history and physical note is incomplete or otherwise deficient.
1. Unsatisfactory
0 points
The history and physical note is not included.
Assessment and Clinical Impressions
10 points
Criteria Description
Assessment and Clinical Impressions (Identification of Three Differential Diagnoses, List of Acute and Chronic Diagnoses, List of Diagnoses and Conditions in Priority Order)
5. Target
10 points
The assessment and clinical impressions are thoroughly explored and clearly explained with relevant details and support.
4. Acceptable
9 points
The assessment and clinical impressions are provided with appropriate details and support.
3. Approaching
8 points
The assessment and clinical impressions are present, but only minimal detail or support is provided.
2. Insufficient
5 points
The assessment and clinical impressions are incomplete or otherwise deficient.
1. Unsatisfactory
0 points
The assessment and clinical impressions are not included.
Plan and Criteria Incorporation
10 points
Criteria Description
Plan Component Management and Criteria Incorporation (Interventions, Disposition, Expected Outcomes, Health Education, and Case Summary)
5. Target
10 points
The plan component management and plan criteria incorporation are thoroughly explored and clearly explained with relevant details and support.
4. Acceptable
9 points
The plan component management and plan criteria incorporation are provided with appropriate details and support.
3. Approaching
8 points
The plan component management and plan criteria incorporation are present, but only minimal detail or support is provided.
2. Insufficient
5 points
The plan component management and plan criteria incorporation are incomplete or otherwise deficient.
1. Unsatisfactory
0 points
The plan component management and plan criteria incorporation are not included.
Peer-Reviewed Articles
10 points
Criteria Description
Peer-Reviewed Articles
5. Target
10 points
Three peer-reviewed articles are included.
4. Acceptable
9 points
N/A
3. Approaching
8 points
N/A
2. Insufficient
5 points
Fewer than three peer-reviewed articles are provided.
1. Unsatisfactory
0 points
Three peer-reviewed articles are not included.
Mechanics of Writing
5 points
Criteria Description
Includes spelling, punctuation, grammar, language use.
5. Target
5 points
Writer is clearly in command of standard, written, academic English.
4. Acceptable
4.5 points
Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech.
3. Approaching
4 points
Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct and varied sentence structure and audience-appropriate language are employed.
2. Insufficient
2.5 points
Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied.
1. Unsatisfactory
0 points
Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used.
Format/Documentation
5 points
Criteria Description
Uses appropriate style, such as APA, MLA, etc., for college, subject, and level; documents sources using citations, footnotes, references, bibliography, etc., appropriate to assignment and discipline.
5. Target
5 points
No errors in formatting or documentation are present. Selectivity in the use of direct quotations and synthesis of sources is demonstrated.
4. Acceptable
4.5 points
Appropriate format and documentation are used with only minor errors.
3. Approaching
4 points
Appropriate format and documentation are used, although there are some obvious errors.
2. Insufficient
2.5 points
Appropriate format is attempted, but some elements are missing. Frequent errors in documentation of sources are evident.
1. Unsatisfactory
0 points
Appropriate format is not used. No documentation of sources is provided.
Total 50 points
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Assessment Description
Academic clinical history and physical notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating evidence-based plans of care.
Complete an academic clinical history and physical note based on a patient seen during clinical/practicum. In your assessment, provide the following:
History and Physical Note
1. Chief complaint/reason for admission/visit/consult.
2. HPI for the H&P or consult notes.
3. Medical, surgical, family, social, and allergy history.
4. Home medications, including dosages, route, frequency, and current medications, if a consultation note.
5. Review of systems with all body systems for H&P or consult notes. Review of systems is what the patient or family/friends tell you (by body system).
6. Vital signs and weight.
7. Physical exam with a complete head-to-toe evaluation. Include pertinent positives and negatives based on findings from head-to-toe exam.
8. Lab/Imaging/Diagnostic test results (including date).
Assessment and Clinical Impressions
1. Identify at least three differential diagnoses based upon the chief complaint, ROS, assessment, or abnormal diagnostic tools with rationale.
2. Include a complete list of all diagnoses that are both acute and chronic.
3. List the differential diagnoses and chronic conditions in order of priority.
Plan Component Management and Plan Criteria Incorporation
1. Select appropriate diagnostic and therapeutic interventions based on efficacy, safety, cost, and acceptability. Provide rationale.
2. Discuss disposition and expected outcomes.
3. Identify and address health education, health promotion, and disease prevention.
4. Provide a case summary with ethical, legal, and geriatric considerations. Compare treatment options specific to the geriatric population to nongeriatric adult populations. Consider potential issues, even if they are not evident.
General Requirements
This assignment uses a template. Please refer to the “History and Physical Note Template,” located on the Student Success Center page under the AGACNP tab.
Incorporate at least three peer-reviewed articles in the assessment or plan.
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite Technical Support Articles is located in Class Resources if you need assistance.
ANP- 650
Academic Clinical History and physical Note
Student Name: Theresa Davis-Bates Date: 12-10-2019
PATIENT PROFILE
Patient Initials: B. M.
DOB: 10-18-1927
Sex: Female
Race: Hispanic
Marital Status: widowed
Admit Date: 12-06-2019
Allergies: NKDA
Chief Complaint: Dizziness, syncope
History of Present Illness:
This is a 92-year-old Hispanic female who was brought into ER
with CC of dizziness and syncope. She was washing dishes
at her nephews birthday party when she fell. Patient reports
the dizziness has been going on for a year, but this is the first
time she has fallen and blacked out for a second. Patient
reports she woke up when she hit her head. Patient denies any
nausea, vomiting, headaches, chest pain, or recent ear
infections. She also reports her blood pressure has been elevated,
and
when she takes her medication, standing makes her dizzy. I
had patient stand as if she was going to the bathroom, and she
became dizzy right away. Patient also reports bright red
blood in stool per rectum with history of hemorrhoids. Reports
history of chronic constipation. Denies abdominal pain or
discomfort, no loose stools. HGB stable-11.3. Patient has been
hospitalized for severe constipation in the past.
Past Medical History:
? Type 2 diabetes Mellitus non-insulin dependent
? Hypertension
? Hyperlipidemia
? COPD
? Chronic constipation
? Hemorrhoids
Surgical Medical History:
? Right leg surgery: Pt does not know what type of surgery
? Bladder lift
Medications:
? ProAir 90mcg/inh 1 puff inhaled orally BID
? Atorvastatin 20mg 1 tab PO daily
? Benazepril 10mg 1 tab PO BID
? Lactulose 10g/15ml PO 30ml BID PRN- Constipation
? Meclizine 25mg 1 tab PO Q8h as needed- dizziness
? Pantoprazole 40mg 1 tab PO daily
? Psyllium 3.4g/7g oral powder daily
Social/Personal History:
? Patient lives with sister and family. Sister is caregiver.
? Widowed.
? Denies smoking, recreational drug use, or use of alcohol.
? DNR status
Family History:
? Mother and brother: Diabetes
? Unknown if anyone had CAD or cancer
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ANP 650 Clinical History and Physical Note
Review of Systems:
? Constitutional: Denies fever/chills, weight gain or loss,
or fatigue
? Head: Positive head pain from fall, Denies lightheadedness,
confusion
? Eyes: Denies vision changes or blurriness
? ENT: Positive hard of hearing and vertigo. Denies tinnitus,
nasal drainage or stuffiness, denies any sore throat or
swallowing issues
? Skin: Denies skin changes or rash, no pruritis, bleeding or
bruising
? Cardiac: Denies chest pain, palpitations, edema, or PND
? Pulmonary: Denies SOB, wheezing, sputum production, or
cough
? GI: Positive bloody stools and constipation. Denies
dysphagia, abdominal pain, N/V/D
? GU: Positive urgency, hx bladder surgery. Denies any
dysuria, incontinence, polyuria, or hematuria
? Neurology: Positive dizziness. Denies focal weakness,
num/ting, neck stiffness, seizures or stroke
? Musculoskeletal: Positive back pain. Denies joint pain,
swelling, arthralgia
? Psychiatric: Denies stress, anxiety, or depression
Vital Signs: BP: 180/51, HR: 73, RR: 16, temp: 98.1, O2 sat: 95%
RA (12-07-19 0800)
? 12-07-19 1230pm: Orthostatic BP: lying- 122/68; standing-
82/56 (+)
Measurements: Weight: 64kg, Height 155cm, BMI 27
Physical Exam:
? General: Normal hygiene, affect, no apparent distress,
appears younger than age
? Head: no scars, deformities, bumps, or open wounds
? Eyes: Pupils equal, round, and reactive to light. No
icterus
? ENT: hard of hearing, no nasal drainage, lymphadenopathy,
exudate. Trachea midline
? Cardiac: heart tones normal, regular rate/rhythm, no
murmurs/rubs/gallops, no edema
? Pulmonary: no wheezes/rales/rhonchi, clear to auscultation,
no distress, symmetrical chest wall expansion
? GI: BS active/normal, no bruits, non-tender/distended
? Genitourinary: no Foley catheter, no UTI
? Skin: no rashes, bruises, or open wounds
? Neurology: bilateral grip strong, normal sensation, tongue
midline, and normal movements; unsteady gait/standing
? MSK: normal ROM to upper and lower extremities
? Lymphatics: no lymphadenopathy
? Mental status: awake, alert, oriented x 3, obeys command,
communicate appropriately
Labs (12-07-19):
? CBC: WBC 6.8, RBC 3.52, H/H 11.3/33.1, MCV 94.0, MCH 32,
PLT 164,
? Chemistry: NA 140, K+ 4.0, Cl 106, BUN/Cr 43/1.58, Bili
1.5, Lac 1.20, Mg 2.21, Co2 24, AGAP 14, Glu 115, ALT
13.0, AST 22, lipase 23, T-pro 7.50, GFR 30.6
? Cardiac: troponin I 0.050
? Coags: PT 10.8, INR 1.0
? Occult stool: negative
Imaging (12-06-19):
? CXR 1 view: Impression- Stable chronic post-inflammatory
changes. No acute distress.
? CT brain w/o contrast: Impression- Age-related senescent
changes. No acute intracranial abnormality. Sinusitis.
EKG
? NSR with rate 80, no St elevations or depressions, T-wave
inversion, R. BBB
Assessment/Plan:
DDx:
? Syncope secondary to orthostatic hypotension
o Orthostatic BP standing dropped to 82/56.
o Orthostatic hypotension often occurs in the older
population, > 65 yrs. Hardening of the arteries develops as
age increases; this makes it more difficult for blood vessels to quickly adapt, as needed. As well as the other
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ANP 650 Clinical History and Physical Note
progressive diseases that are associated with orthostatic
hypotension becomes worse in the elderly
(MedicineNet, 2019). The patient is 92 y/o.
o Blood loss, dehydration, and anemia are a few of the most
common reasons for orthostatic hypotension
(MedicineNet, 2019).
o High blood pressure medications can result in orthostatic
hypotension
? Bleeding internal hemorrhoids (K62.5):
o Being constipated and straining can damage the surface
hemorrhoids, causing them to bleed. This could
happen with both internal and external (Healthline, 2018). Pt
had blood in stool and a history of both
hemorrhoids and chronic constipation.
Dx/Plan:
? Consults: Cardiology: To manage hypertension and
orthostatic hypotension
? Orthostatic hypotension due to Syncope episode (I95.1)
o Midodrine 2.5mg 1 tab PO TID: short-acting pressors to assist
in hypotension. Hypertension is a risk factor
for orthostatic hypotension and both common in older adults.
While certain hypertensive medicines can
trigger orthostatic hypotension, total withdrawal is not
appropriate (Epocrates, 2019).
o Decrease Benezapril to 10 mg 1 tab daily for SBP >150:
according to the Journal of Hypertension, target
BP for the elderly >60 years of age is 150/90 (Currie
& Delles, 2018). However, this number is not set in
stone, and it depends on the frailty of the patient. Careful
use of antihypertensives like ACEI or ARBs, and
avoiding medicines that are likely to cause orthostatic
hypotension, for instance, alpha-blockers, diuretics
(Epocrates, 2019).
o IVF for hydration: Dehydration is one of the common causes of
orthostatic hypotension, and treating the
underlined cause is recommended. The patients Creat 1.58 (was
1.69 on admission) and liver enzymes are
slightly elevated; this could be due to dehydration.
? Acute kidney injury (N17.9): Creat 1.69 on admission 12-06-19,
then 1.58 next blood draw 12-07-19, liver
enzymes slightly elevated.
o IVF for hydration, as mentioned above. Signs and symptoms of
dehydration include postural dizziness and
hypotension, fatigue, chest pain, and last but not limited to
tachycardia (Epocrates, 2019).
o Monitor labs CMP and CBC: to monitor Bun/cr, H/H, and lytes
(Epocrates, 2019).
? Dehydration (E86.0):
o Same plan as above.
? Bleeding internal hemorrhoids (K62.5): Pt reported bright
red blood in stools.
o Occult stool (-)
o Stool softener to prevent straining. Being constipated and
straining can damage the surface hemorrhoids,
causing them to bleed. This could happen with both internal and
external (Healthline, 2018). Pt had blood in
stool and a history of both hemorrhoids and chronic
constipation
? Type 2 DM (E11.9)
o Accu checks AC/HS with insulin sliding scale. Although
patient diabetes is well controlled and does not take
diabetes medication, hospital admits, and acute illness causes
stress, which increases glucose levels.
? CKD 3B due to diabetes (N18.3)
o Continue ACEI: studies indicated w/ advance CKD and stable
HTN, antihypertensives treatments with
ACEI/ARBs reduce the chances of long-term dialysis and lower
mortality risk (Medscape, 2019).
o Keep blood glucose controlled. To delay or slow the
progression of CKD.
? Hypertensive CKD w/ stage 1 through stage 4 chronic kidney
disease, Type 2 DM (I1.29)
o Benazepril 10mg 1 tab daily if SBP >150. According to
Currie & Delles (2018), the elderly > 65 can
maintain BP of 150/90.
o Vital signs Q4H: monitor BP
? Anemia secondary CKD (D63.8).
o Labs: CBC in AM. Last HGB 11.3. Stable
Disposition and Expected Outcomes
? Admit to telemetry unit: to continuously monitor cardiac
rhythm and Q4 vital signs
? Counsel patient and patients family regarding diagnosis,
diagnostic reports, treatment plan
? I discussed with patient the planned work-up and the need
to follow up as outpatient with PCP and cardiology when
discharged
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ANP 650 Clinical History and Physical Note
? The expected outcome will be to discharge home within a couple
of days, if assist readily available in the home, or
admit to rehab for PT/OT and to monitor blood pressure. The
patient understands the plan of care.
Health education/ health promotion/ disease prevention (RHIhub,
2019).
? Identify opportunities for health promotion and education
? Understand the potential barriers
? Know what is easily accessible to the patient and the
patient population.
? Understand the cultural and social issues
? Resources and sustainability
Ethical and Geriatric considerations
? Respect for the patient’s autonomy
? Providers should adequately inform them of their illness
and treatment options
? Patients of age must have thinking capacity to give
informed consent
When any of these ethical principles are overlooked, a
clinician may be at risk for neglect or abuse. Clinicians should
prevent elder neglect and abuse (ASA, n.d).
References
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ANP 650 Clinical History and Physical Note
American Society in aging [ASA] (n.d). Ethical Caregiving and Protecting Elders. Retrieved from
https://allaplusessays.com/order
Curries, G. & Delles, C. (2018). Blood pressure targets in the elderly. Journal of Hypertension 36(2). Retrieved from
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#pdf-link
Epocrates (2019). Orthostatic hypotension; dehydration; and CKD. Retrieved from https://allaplusessays.com/order
Healthline (2018). How to manage bleeding hemorrhoids. Retrieved from
https://allaplusessays.com/order
MedicineNet (2019). Orthostatic Hypotension (Low Blood Pressure When Standing). Retrieved from
https://allaplusessays.com/order
Medscape (2019). Chronic kidney disease. Retrieved from https://allaplusessays.com/order
Rural health information hub [RHIhub] (2019). Health promotion and disease prevention. Retrieved from
https://allaplusessays.com/order
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