Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s
own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section
is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the
patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with
age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each
principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the
HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not
completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also
include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of
what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs
intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major
illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous
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Page 1 of 3
and current use), any other pertinent data. Always add some health promo question here – such as
whether they use seat belts all the time or whether they have working smoke detectors in the
house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason
for death of any deceased first degree relatives should be included. Include parents, grandparents,
siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You
should list each system as follows: General: Head: EENT: etc. You should list these in bullet
format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose,
Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or
edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or
blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or
tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or
polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
© 2021 Walden University, LLC
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O.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your
physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and
History. Do not use “WNL” or “normal.” You must describe what you see. Always
document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the
differential diagnoses (support with evidenced and guidelines)
A.
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or
presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive
documentation with evidence based guidelines.
P.
This section is not required for the assignments in this course (NURS 6512) but will be required
for future courses.
References
You are required to include at least three evidence based peer-reviewed journal articles or
evidenced based guidelines which relates to this case to support your diagnostics and
differentials diagnoses. Be sure to use correct APA 7th edition formatting.
© 2021 Walden University, LLC
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CASE STUDY ASSIGNMENT:
ASSESSING THE HEAD, EYES, EARS,
NOSE, AND THROAT
Nurses conducting assessments of the
ears, nose, and throat must be able to identify the small differences between lifethreatening conditions and benign ones. For instance, if a patient with a sore throat and
a runny nose also has inflamed lymph nodes, the inflammation is probably due to the
pathogen causing the sore throat rather than a case of throat cancer. With this
knowledge and a sufficient patient health history, a nurse would not need to escalate
the assessment to a biopsy or an MRI of the lymph nodes but would probably perform a
simple strep test.
Most ear, nose, and throat conditions that arise in non-critical care settings are minor in
nature. However, subtle symptoms can sometimes escalate into life-threatening
conditions that require prompt assessment and treatment.
In this Case Study Assignment, you consider case studies of abnormal findings from
patients in a clinical setting. You determine what history should be collected from the
patients, what physical exams and diagnostic tests should be conducted, and formulate
a differential diagnosis with several possible conditions.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
TO PREPARE
•
•
By Day 1 of this week, you will be assigned to a specific case study for this
Case Study Assignment. Please see the “Course Announcements” section of
the classroom for your assignment from your Instructor.
Also, your Case Study Assignment should be in the Episodic/Focused SOAP
Note format rather than the traditional narrative style format. Refer to Chapter
2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week
5 Learning Resources for guidance. Remember that all Episodic/Focused
SOAP Notes have specific data included in every patient case.
With regard to the case study you were assigned:
•
•
•
•
Review this week’s Learning Resources and consider the insights they
provide.
Consider what history would be necessary to collect from the patient.
Consider what physical exams and diagnostic tests would be appropriate to
gather more information about the patient’s condition. How would the results
be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a
differential diagnosis for the patient.
THE ASSIGNMENT
Use the Episodic/Focused SOAP Template and create an episodic/focused note about
the patient in the case study to which you were assigned using the episodic/focused
note template provided in the Week 5 resources. Provide evidence from the literature to
support diagnostic tests that would be appropriate for each case. List five different
possible conditions for the patient’s differential diagnosis and justify why you selected
each.
Below is the case study.
CASE STUDY 1: Focused Nose Exam Richard is a 50-year-old male with nasal congestion,
sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy nose, eyes,
palate, and ears for 5 days. As you check his ears and throat for redness and inflammation, you
notice him touch his fingers to the bridge of his nose to press and rub there. He says he’s taken
Mucinex OTC the past 2 nights to help him breathe while he sleeps. When you ask if the
Mucinex has helped at all, he sneers slightly and gestures that the improvement is only minimal.
Richard is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and
enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. His tonsils are not
enlarged but his throat is mildly erythematous.
•
Also, your Case Study Assignment should be in the Episodic/Focused SOAP
Note format rather than the traditional narrative style format. Refer to Chapter
2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week
5 Learning Resources for guidance. Remember that all Episodic/Focused
SOAP Notes have specific data included in every patient case.
You will have to add to this case as you have in the past. The information provided is
all that we give you for this focused note. Please look back at the assignment overview
post if you are not sure about what should be turned in.
Required Readings
•
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Seidel’s guide to physical examination: An interprofessional
approach (9th ed.). St. Louis, MO: Elsevier Mosby.
o Chapter 11, “Head and Neck”
▪ This chapter reviews the anatomy and physiology of the
head and neck. The authors also describe the
procedures for conducting a physical examination of the
head and neck.
o Chapter 12, “Eyes”
▪
▪
•
In this chapter, the authors describe the
anatomy and function of the eyes. In addition,
the authors explain the steps involved in
conducting a physical examination of the eyes.
▪ Chapter 13, “Ears, Nose, and Throat”
▪ The authors of this chapter detail the proper
procedures for conducting a physical exam of
the ears, nose, and throat. The chapter also
provides pictures and descriptions of common
abnormalities in the ears, nose, and throat.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health
assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th
Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted
by permission of Mosby via the Copyright Clearance Center.
o Chapter 15, “Earache”Download Chapter 15, “Earache”
This chapter covers the main questions that need to be asked
about the patient’s condition prior to the physical examination as
o
o
o
o
o
•
•
•
well as how these questions lead to a focused physical
examination.
Chapter 21, “Hoarseness”Download Chapter 21, “Hoarseness”
This chapter focuses on the most common causes of hoarseness.
It provides strategies for evaluating the patient, both through
questions and through physical exams.
Chapter 25, “Nasal Symptoms and Sinus Congestion”Download
Chapter 25, “Nasal Symptoms and Sinus Congestion”
In this chapter, the authors highlight the key questions to ask about
the patients symptoms, the key parts of the physical examination,
and potential laboratory work that might be needed to provide an
accurate diagnosis of nasal and sinus conditions.
Chapter 30, “Red Eye”Download Chapter 30, “Red Eye”
The focus of this chapter is on how to determine the cause of red
eyes in a patient, including key symptoms to consider and possible
diagnoses.
Chapter 32, “Sore Throat”Download Chapter 32, “Sore Throat”
A sore throat is one most common concerns patients describe. This
chapter includes questions to ask when taking the patient’s history,
things to look for while conducting the physical exam, and possible
causes for the sore throat.
Chapter 38, “Vision Loss”Download Chapter 38, “Vision Loss”
This chapter highlights the causes of vision loss and how the
causes of the condition can be diagnosed.
Note: Download the six documents (Student Checklists and Key
Points) below, and use them as you practice conducting
assessments of the head, neck, eyes, ears, nose, and throat.
Document: Episodic/Focused SOAP Note Exemplar Download
Episodic/Focused SOAP Note Exemplar(Word document)
Document: Episodic/Focused SOAP Note Template Download
Episodic/Focused SOAP Note Template(Word document)
Document: Midterm Exam Review Download Midterm Exam Review(Word
document)
Shadow Health Support and Orientation Resources
•
•
•
•
Shadow Health. (2021). Welcome to your introduction to Shadow HealthLinks
to an external site.. https://link.shadowhealth.com/Student-Orientation-Video
Shadow Health. (n.d.). Shadow Health help deskLinks to an external site..
Retrieved from https://support.shadowhealth.com/hc/en-us
Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP
students. Download Walden University quick start guide: NURS 6512 NP
students. https://link.shadowhealth.com/Walden-NURS-6512-Student-Guide
Document: DCE (Shadow Health) Documentation Template Download DCE
(Shadow Health) Documentation Templatefor Focused Exam: Cough (Word
document)
Use this template to complete your Assignment 2 for this week.
Rubric
NURS_6512_Week_5_Assignment_1_Rubric
NURS_6512_Week_5_Assignment_1_Rubric
Criteria
This criterion is linked to
a Learning
OutcomeUsing the
Episodic/Focused SOAP
Template: · Create
documentation or an
episodic/focused note in
SOAP format about the
patient in the case study
to which you were
assigned. · Provide
evidence from the
literature to support
diagnostic tests that
would be appropriate for
your case.
Ratings
50 to >44.0 pts
Excellent
The response clearly,
accurately, and
thoroughly follows the
SOAP format to
document the patient in
the assigned case
study. The response
thoroughly and
accurately provides
detailed evidence from
the literature to support
diagnostic tests that
would be appropriate
for the patient in the
assigned case study.
44 to >38.0 pts
Good
The response
accurately follows
the SOAP format to
document the patient
in the assigned case
study. The response
accurately provides
detailed evidence
from the literature to
support diagnostic
tests that would be
appropriate for the
patient in the
assigned case study.
38 to >32.0 pts
Fair
The response follows
the SOAP format to
document the patient in
the assigned case study,
with some vagueness
and inaccuracy. The
response provides
evidence from the
literature to support
diagnostic tests that
would be appropriate for
the patient in the
assigned case study,
with some vagueness or
inaccuracy in the
evidence selected.
32 to >0 pts
Poor
The response
incompletely and
inaccurately follo
SOAP format to
document the pa
the assigned case
The response pro
incomplete, inac
and/or missing e
from the literatur
support diagnost
that would be
appropriate for th
patient in the ass
case study.
NURS_6512_Week_5_Assignment_1_Rubric
Criteria
This criterion is linked to
a Learning
Outcome· List five
different possible
conditions for the
patient’s differential
diagnosis, and justify
why you selected each.
This criterion is linked to
a Learning
OutcomeWritten
Expression and
Formatting – Paragraph
Development and
Organization: Paragraphs
make clear points that
support well-developed
ideas, flow logically, and
demonstrate continuity
of ideas. Sentences are
carefully focused-neither long and
rambling nor short and
lacking substance. A
clear and comprehensive
purpose statement and
introduction are provided
that delineate all required
criteria.
Ratings
35 to >29.0 pts
Excellent
The response lists five
distinctly different and
detailed possible
conditions for a
differential diagnosis of
the patient in the
assigned case study, and
provides a thorough,
accurate, and detailed
justification for each of
the five conditions
selected.
29 to >23.0 pts
Good
The response lists four
or five different
possible conditions for
a differential diagnosis
of the patient in the
assigned case study
and provides an
accurate justification
for each of the five
conditions selected.
23 to >17.0 pts
Fair
The response lists
three to five possible
conditions for a
differential diagnosis
of the patient in the
assigned case study,
with some vagueness
and/or inaccuracy in
the conditions and/or
justification for each.
17 to >0 pts
Poor
The response l
or fewer, or is
possible condi
a differential d
of the patient i
assigned case s
with inaccurate
missing justific
for each condit
selected.
5 to >4.0 pts
Excellent
Paragraphs and sentences
follow writing standards
for flow, continuity, and
clarity. A clear and
comprehensive purpose
statement, introduction,
and conclusion are
provided that delineate all
required criteria.
4 to >3.0 pts
Good
Paragraphs and
sentences follow
writing standards for
flow, continuity, and
clarity 80% of the time.
Purpose, introduction,
and conclusion of the
assignment are stated,
yet are brief and not
descriptive.
3 to >2.0 pts
Fair
Paragraphs and
sentences follow
writing standards for
flow, continuity, and
clarity 60%–79% of
the time. Purpose,
introduction, and
conclusion of the
assignment are vague
or off topic.
2 to >0 pts
Poor
Paragraphs an
sentences foll
writing standa
flow, continu
clarity < 60%
time. No purp
statement,
introduction,
conclusion w
provided.
NURS_6512_Week_5_Assignment_1_Rubric
Criteria
Ratings
This criterion is linked to
a Learning
OutcomeWritten
Expression and
Formatting - English
writing standards:
Correct grammar,
mechanics, and proper
punctuation
5 to >4.0 pts
Excellent
Uses correct
grammar, spelling,
and punctuation
with no errors.
This criterion is linked to
a Learning
OutcomeWritten
Expression and
Formatting – The paper
follows correct APA
format for title page,
headings, font,
spacing, margins,
indentations, page
numbers, running heads,
parenthetical/in-text
citations, and reference
list.
5 to >4.0 pts
Excellent
Uses correct APA
format with no errors.
Total Points: 100
PreviousNext
4 to >3.0 pts
Good
Contains a few (1 or
2) grammar, spelling,
and punctuation
errors.
3 to >2.0 pts
Fair
Contains several (3
or 4) grammar,
spelling, and
punctuation errors.
4 to >3.0 pts
Good
Contains a few (1 or 2)
APA format errors.
2 to >0 pts
Poor
Contains many (≥ 5) gr
spelling, and punctuatio
that interfere with the r
understanding.
3 to >2.0 pts
Fair
Contains several (3 or 4)
APA format errors.
2 to >0 pts
Poor
Contains many
APA format er
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Formatting
Title Page
Citation
Outline
