28 Mar Typing Template for SOAP notes: A Sample for NU664B and NU665B

Typing Template for SOAP notes: A Sample for NU664B and NU665B

Assessment

This is the differential diagnosis section. List FOUR differential / working diagnoses. One of these will be your final diagnosis. For EACH of your diagnoses, list a brief rationale indicating why this diagnosis should be considered or not considered as the final diagnosis. Include references used to guide your thinking.

1.      

2.      

3.      

4.      

Final Diagnosis:

Plan

All plans until you graduate contain the following elements. If an item does not apply to the particular situation, please indicate not applicable or not needed at this time. If it’s not indicated, it is assumed to not have been addressed.

Pharmacology

Medications—both prescription and OTC—go here. Write out your prescription meds just like a prescription.

Non-Pharmacology

What non-pharmacologic interventions do you recommend for your patient?

Diagnostics

Are there any lab tests, radiology, or other diagnostics you would like to order? Remember to think primary care. No troponins or bedside stat echos in the office.

Consults/Referrals

Would you like to phone a friend? Should they follow up with a specialist for additional or further care?

Patient Education

What important information do you need to make certain they know? Don’t forget about serious medication interactions or OCP.

Follow Up

Think about how much leeway you want to give this patient before someone lays eyes on them again? One week? Two? What should they do if they experience new or worsening symptoms?

Sample Plan

Here is how this needs to look on i-Human submissions: (This is a sample only—do not include in your submission.)

Pharmacology:

·       Ramipril 10mg 1 tablet PO QD

·       Norvasc 5mg 1 tablet PO QHS

·       HCTZ 12.5mg 1 tablet PO QAM

·       (more if needed)

Non-pharmacology

·       DASH diet

·       Lifestyle modifications: exercise, etc.

·       Avoid caffeine and other stimulants

·       (more if needed)

Labs

·       CBC (anemia, “paleness,” fatigue)

·       CMP (liver function, renal function, electrolytes, nutrition status)

·       BNP (cardiac dysfunction)

·       Microalbumin (kidney function—due annually for htn/dm patients)

·       (more if needed)

Diagnostics

·       EKG

·       ECHO

·       Stress test

·       Sleep study

·       (more if needed)

Patient education

·       Compression stockings may help with the edema as will reducing the calcium channel blocker. You need to check your blood pressure twice a day before you take your medications and keep a log. Please bring this log to your appointments.

·       Address the benefits and limitations to each medication. Address common side effects and the patient goals. Also, address common education topics.

·       (more if needed)

Referrals

·       Cardiology

·       (more if needed)

Follow up

 

·       Follow-up appointment in 1 week to address medication changes and review additional laboratory results (CITATIONsA, 2020; CITATIONsB, 2020)