SOAP Note Respiratory Condition Acute or Chronic
SOAP Note: Respiratory Condition Acute or Chronic (3 pages)
Students will complete 4 Focused SOAP notes on three different patients and three different diagnoses
that have been pre-selected for you. For this SOAP you have the opportunity of selecting a Respiratory
condition (Acute or Chronic) (Pneumonia, COPD, Asthma Bronchitis) . I look forward to seeing what you
select. Visits for refills of medications are not acceptable for this assignment.
Instructions:
* You will focus on a patient with a new or existing RESPIRATORY condition who is being started on a
new medication or whose current medications are being adjusted. A visit for refills without additional
clinical decision-making will not be accepted.
1. SOAPs must be the student’s own work. If sections of the SOAP are not the student’s work, for
example, from a preceptor’s note it should be identified by italics. A SOAP template is provided.
No identifying information should be included in the note, which would be considered a HIPPA
violation.
2. SOAP notes submitted for the course include more information than the notes that students may
submit in clinical. The submitted note is used for coaching and evaluation of the student’s
progress in developing clinical and diagnostic thinking.
3. Clinical Decision Making: This section is designed to further assist in your learning from this
patient case and disease process. Ensure to address the questions in their entirety. (See
template).
4. References used in your SOAP should include a “Reference” heading at the end and in APA
format.
5. Do not forget to look at the Rubric.
Focused SOAP Template
Student Name
Course:
Assignment:
Date:
SUBJECTIVE: (only what the patient tells you; not findings from the physical exam)
C/C:
HPI: OLDCARTS
Review of Systems:
General or Constitutional:
HEENT:
Skin:
Neck:
CV:
Respiratory
Gastrointestinal
Genitourinary/Gynecological
Musculoskeletal
Neurological
PMH/PSH:
Fam Hx:
Social Hx:
Meds:
Allergies:
Immunizations: (
OBJECTIVE: (only findings from the physical exam; not what the patient tells you)
Vital Signs
Labs/procedures: (these are point of care diagnostics) glucose, A1c, Rapid Strep, UA, Orthostatics, or
labs recently drawn in preparation for today’s visit.
Physical Examination:
General or Constitutional:
HEENT:
Skin/Hair/Nails:
Neck:
CV:
Respiratory
Gastrointestinal
Genitourinary/Gynecological
Musculoskeletal
Neurological
ASSESSMENT:
Problem List (Dx#1): Include ICD-10 and CPT codes.
Differential Dx: A list of 3-4 which includes your final diagnosis.
Rationale: Discuss why the one diagnosis was selected and then why the others were not.
Example
Dx#1: Essential Hypertension (I10) (CPT:99213)
Diff Dx: Elevated blood pressure without a diagnosis of hypertension, Anxiety, Secondary Hypertension,
Malignant Hypertension…(provide at least three for each actual diagnosis unless chronic in nature and
no reason to believe there are alternate concerns affecting)
Rationale: (provide reasoning for the selected dx and why it is not likely that other diffs are correct)
PLAN:
Dx #1
Treatment:
Diagnostics:
Education:
Referrals:
Follow-up:
Clinical Decision Making (1 pages):
At the conclusion of your SOAP, you will elaborate on the following elements listed below. Ensure to be
thorough and to base your evidence on credible references.
1. Discuss lab work/diagnostics ordered and how results guided the patient’s care.
2. Discuss the rationale for the selected non-pharm or pharmacological treatment choice and
provide patient-relevant side-effects that needed to be discussed with the patient and perhaps
monitored.
3. Discuss challenges you may have experienced and areas that you identified as needing
improvement, i.e communication, assessment, pharm, history taking, etc.
4. What was one key takeaway from this patient case?
5. What you would do differently and “why”. I appreciate your critical thinking and I do not want
you to automatically agree with the status quo. Whether you agree or disagree with a diagnosis
or treatment plan I want you to support the plan of care with evidence (Evidence-based
Practice). If you disagree with any aspect of the plan of care support your rationale.
6. Observations of situations that elicit insights into your own future practice.
7. Resources used to support your learning of this patient case (a reference page is required- APA
format).