INSTRUCTION: Using the blank SOAP Note Template (found in the Learning Materials module), complete a comprehensive SOAP Note for a patient in your target patient population.
S: Subjective
39-year-old G3P2 female at 33 weeks and 5 days gestation presents for routine high-risk prenatal visit. Pregnancy is complicated by diabetes mellitus and chronic hypertension. Patient reports good fetal movement. Denies vaginal bleeding, leakage of fluid, contractions, headache, visual disturbances, right upper quadrant pain, chest pain, shortness of breath, or decreased fetal movement. Reports compliance with prescribed medications, prenatal vitamins, blood glucose monitoring, and blood pressure monitoring.
O: Objective
BP: 132/81, HR: 87, RR: 18, SaO2: 97%, Temp: 98.1°F
General: Alert and oriented, no acute distress.
Vital Signs: Reviewed and stable.
Blood Pressure: Monitored due to history of hypertension.
Abdomen: Gravid, soft, non-tender.
Fundal Height: Consistent with gestational age.
Fetal Heart Rate: 140 bpm, reassuring.
Fetal Movement: Present.
Extremities: No significant edema.
Urine dipstick: Negative for protein
Blood glucose log reviewed.
A: Assessment
High-risk pregnancy, third trimester.
ICD-10: O09.93
Pre-existing hypertension complicating pregnancy, third trimester.
ICD-10: O10.913
Diabetes mellitus complicating pregnancy, third trimester.
ICD-10: O24.913
Advanced maternal age multigravida, third trimester.
ICD-10: O09.523
33 weeks gestation of pregnancy.
ICD-10: Z3A.33
P: Plan
Continue routine high-risk prenatal care.
Continue prenatal vitamins daily.
Continue antihypertensive and diabetic medications as prescribed.
Encourage adherence to diabetic diet and regular blood glucose monitoring.
Continue home blood pressure monitoring and maintain log.
Review fetal kick counts and instruct patient to report decreased fetal movement.
Educate regarding signs and symptoms of preeclampsia, including severe headache, visual changes, right upper quadrant pain, and sudden swelling.
Educate regarding signs of preterm labor, including regular contractions, vaginal bleeding, leakage of fluid, and pelvic pressure.
Follow up in 1 week or sooner for any concerns.
INSTRUCTIONS:
Patient Information and Chief Complaint Includes required identifying information and clearly states the chief complaint in concise, appropriate language.
Subjective Data Subjective section is complete, relevant, and well organized, including HPI, pertinent past medical/surgical/family/social history, allergies, immunizations, medications, and ROS as appropriate to the visit.
Objective Data
Objective section is complete, accurate, and focused, including vital signs, physical exam findings, and relevant labs/diagnostics interpreted during the visit as appropriate. : (FOR PHYSICAL ASSESSMENT (EXAMPLE): please review proper PE documentation (health assessment course). What does the rash look like? Provide specific location of the rash, upper arm, medial arm? See exams below: Chest: normal AP diameter, symmetrical expansion, normal tactile fremitus bilaterally, clear on percussion and auscultation. No wheezes, rales or rhonchi heard. Cardiovascular: S1 and S2 normal, physiologic splitting, a loud S4 is present at the cardiac apex, no murmurs or rubs Respiratory: Lung sounds are even and unlabored. No crackles, rhonci or wheezing to auscultation. Able to converse w/o SOB or tachypnea. No sign of respiratory distress or accessory muscle usages. O2 saturation at 98%).
Assessment and Clinical Reasoning Identifies 2-3 appropriate differential diagnoses, includes ICD-10 codes, and supports the primary diagnosis with sound clinical reasoning based on subjective and objective findings supported with one to two references in APA format. (There must have a clinical reasoning based on subjective and objective findings supported with references).
Plan of Care Reflection demonstrates meaningful clinical insight, and the SOAP note is organized, concise, professional, and written at the graduate level with appropriate clinical terminology. Includes at least one to two references beyond the course learning materials.
