[Solved] SOAP note for Trichomoniasis Infection.

Assignment Prompt & Instructions

I am providing a template and also an example of the SOAP and guidelines.  **S** =Subjective data: Patient’s Chief Complaint (CC). **O** =Objective data: Including client behavior, physical assessment, vital signs, and meds. **A** =Assessment: Diagnosis of the patient's condition. Include differential diagnosis P **P** =Plan: Treatment, diagnostic testing, and follow up. Remember this is a gynecological SOAP Note, and it should include GTPAL system in the beginning of HPI. Remember to use citations for diagnosis, medications, anticipatory guidance, Just follow the example I have attached below.

Demographics

**1 to >0.8 pts**

**Begins with patient initials, age, race, ethnicity and gender (5 demographics)**

Chief Complaint (Reason for seeking health care)

**4 to >3 pts**

**Includes a direct quote from patient about presenting problem**

History of the Present Illness (HPI)

**5 to >3 pts**

**Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)**

Allergies

**2 to >1.5 pts**

**Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)**

Review of Systems (ROS)

**15 to >8 pts**

**Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to chief complaint AND uses the words “admits” and “denies”**

Vital Signs

**2 to >1.5 pts**

**Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)**

Labs

**2 to >1.5 pts**

**Includes a list of the labs reviewed at the visit, values of lab results and highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed.**

Medications

**4 to >2 pts**

**Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)**

Past Medical History

**3 to >2 pts**

**Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current**

Past Surgical History

**3 to >2 pts**

**Includes, for each surgical procedure, the year of procedure and the indication for the procedure**

Family History

**3 to >2 pts**

**Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.**

Social History

**3 to >2 pts**

**Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.**

Health Maintenance / Screenings

**3 to >2 pts**

**Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests**

Physical Examination

**15 to >8 pts**

**Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint.**

Diagnosis

**5 to >3 pts**

**Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)**

Differential Diagnosis

**5 to >3 pts**

**Includes at least 3 differential diagnoses for the principal diagnosis**

ICD 10 Coding

**3 to >2 pts**

**Correctly includes all ICD-10 codes relevant to the diagnoses addressed at the visit**

Pharmacologic treatment plan

**5 to >3 pts**

**Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.**

Diagnostic / Lab Testing

**3 to >2 pts**

**Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”**

Education

**3 to >2 pts**

**Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives.**

Anticipatory Guidance

**3 to >2 pts**

**Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))**

Follow Up Plan

**2 to >1 pts**

**Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)**

Prescription

**3 to >2 pts**

**Prescription includes all required components: patient information, date, drug name, dose,**

Writing Mechanics, Citations, and APA Style

**3 to >2 pts**

**Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials**

– [\
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SOAPNoteTemplate.docx](https://www.sweetstudy.com/files/soapnotetemplate-docx-10195005 "SOAPNoteTemplate.docx")
– [\
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SOAP22.docx](https://www.sweetstudy.com/files/soap22-docx "SOAP22.docx")

– 2 years ago