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 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.

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

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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.

Assessment 1

Nursing Informatics in Health Care

INSTRUCTION- Write a 4–5 page evidence-based proposal to support the need for a nurse informaticist in an organization who would focus on improving health care outcomes.

Introduction- Nurses at the baccalaureate level in all practice areas are involved in nursing informatics through interaction with information management and patient care technologies. Nurses must not only demonstrate knowledge of and skills in health information and patient care technologies, but also how to use these tools at the bedside and organizational levels. Moreover, nurses need to recognize how information gathered from various health information sources can impact decision making at the national and state regulatory levels.

Preparation- To successfully prepare for this assessment, you will need to complete these preparatory activities:

· Review assessment resources and activities.

· Conduct independent research on the nursing knowledge and skills necessary to interact with health information and patient care technology.

· Focus your research on current resources available through peer-reviewed articles, professional websites, government websites, professional blogs, wikis, job boards, and so on.

· Consult the 

BSN Program Library Research Guide
 for help in identifying scholarly and authoritative sources.

· Interview peers in your network who are considered information technology experts.

· Ask them about how information technology advances are impacting patient care at the bedside, at the organizational level, and beyond.

Scenario- For this assessment, assume you are a nurse attending a meeting of your state’s nurses association. A nurse informaticist conducted a presentation on her role and its impact on positive patient and organizational outcomes in her workplace. You realize that your organization is undergoing many technological changes. You believe this type of role could provide many benefits to your organization.

You decide to pursue proposing a nurse informaticist role in your organization. You speak to your chief nursing officer (CNO) and human resources (HR) manager, who ask you to prepare a 4–5 page evidence-based proposal to support the new role. In this way, they can make an informed decision as to whether the addition of such a role could justify the return on investment (ROI). They need your proposal before an upcoming fiscal meeting.​ This is not an essay, but instead, it is a proposal to create a new Nurse Informaticist position.

One important part of this assessment is the justification of the need for a nurse informaticist in a health care organization and references from relevant and timely scholarly or professional resources to support the justification for creating this nurse informaticist position. The term justify means to show or prove that the nurse informaticist position brings value to the organization. This justification must include evidence from the literature to support that this position will provide a return on investment for the organization.

Proposal Format- The chief nursing officer (CNO) and human resources (HR) manager have asked you to include the following headings in your 
proposal and to be sure to address the bullets following each heading:

Nursing Informatics and the Nurse Informaticist

· What is nursing informatics?

· What is the role of the nurse informaticist?

Nurse Informaticists and Other Health Care Organizations

· What is the experience of other health care organizations with nurse informaticists?

· How do these nurse informaticists interact with the rest of the nursing staff and the interdisciplinary team?

Impact of Full Nurse Engagement in Health Care Technology

· How does fully engaging nurses in health care technology impact:

· Patient care?

· Protected health information (security, privacy, and confidentiality)?

· In this section, you will explain evidence-based strategies that the nurse informaticist and interdisciplinary team can use to effectively manage patients' protected health information, particularly privacy, security, and confidentiality. Evidence-based means that they are supported by evidence from scholarly sources.

· Workflow?

· Costs and return on investment?

Opportunities and Challenges

· What are the opportunities and challenges for nurses and the interdisciplinary team with the addition of a nurse informaticist role?

· How can the 
interdisciplinary team collaborate to improve quality care outcomes through technology?

Summary of Recommendations

· What are 3–4 key takeaways from your 
proposal about the recommended nurse informaticist role that you want the CNO and the HR manager to remember?

· This is the section where the justification for the implementation of the nursing informaticist role is addressed. Remember to include evidence from the literature to support your recommendation.

·
Additional Requirements-
Written communication: Ensure written communication is free of errors that detract from the overall message.

·
Submission length: 4–5 double-spaced pages, in addition to title and references pages.

·
Font: Times New Roman, 12 point.

·
Citations and References: Cite a 
minimum of three current scholarly and/or authoritative sources to support your ideas. In addition, cite a 
minimum of one current professional blog or website to support your central ideas. 
Current means no more than five years old.

·
APA formatting: Be sure to follow APA formatting and style guidelines for citations and references. For an APA refresher, consult the 

Evidence and APA
 page on Campus.

Competencies Measured- By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

· Competency 1: Describe nurses' and the interdisciplinary team's role in informatics with a focus on electronic health information and patient care technology to support decision making.

· Define nursing informatics and the role of the nurse informaticist.

· Explain how the nurse collaborates with the interdisciplinary team, including technologists, to improve the quality of patient care.

· Justify the need for a nurse informaticist in a health care organization.

· Competency 2: Implement evidence-based strategies to effectively manage protected health information.

· Explain evidence-based strategies that the nurse and interdisciplinary team can use to effectively manage patients’ protected health information (privacy, security, and confidentiality).

· Competency 5: Apply professional, scholarly communication to facilitate use of health information and patient care technologies.

· Follow APA style and formatting guidelines for citations and references.

· Create a clear, well-organized, and professional proposal that is generally free from errors in grammar, punctuation, and spelling.

Scoring Guide

Use the scoring guide to understand how your assessment will be evaluated

Nursing Informatics in Health Care Scoring Guide

CRITERIA	NON-PERFORMANCE	BASIC	PROFICIENT	DISTINGUISHED
Define nursing informatics and the role of the nurse informaticist.

Explain how the nurse informaticist collaborates with the interdisciplinary team, including technologists, to improve the quality of patient care.

Justify the need for a nurse informaticist in a health care organization.

Explain evidence-based strategies that the nurse informaticist and interdisciplinary team can use to effectively manage patients’ protected health information (privacy, security, and confidentiality).

Follow APA style and formatting guidelines for citations and references.

Create a clear, well-organized, and professional proposal that is generally free from errors in grammar, punctuation, and spelling.

Please see attachment for instructions. 

Please see attached.

 If you talk about a possible poor health outcome, do you believe that outcome will occur? Do you believe eye contact and personal contact should be avoided?