SOAP NOTE ASSESSMENT Example

SOAP NOTE ASSESSMENT

A.

In the SOAP Note Assessment section, List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines (include ICD guidelines where applicable). Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.

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.

Here are three examples of SOAP NOTE ASSESSMENT section

SOAP NOTE ASSESSMENT Example 1:

ASSESSMENT:

Differential Diagnoses

  1. Otitis externa (Confirmed)
    1. Associated with recent water exposure. The skin of the outer ear becomes erythematous, swollen, tender, and warm, leading to debris and discharge accumulation. Pain is worse when an otoscope is inserted because sensitivity is on the outer ear. Narrow external auditory canal with purulent discharge (Wiegand et al., 2019). PT meets this diagnosis criteria.
  2. Otitis media with perforation (Refuted)
    1. Clear discharge or bloody followed by relief of pain, with an inflamed tympanic membrane with perforation in the middle ear. Associated with ear pain, fever, difficulty hearing, irritability, and lethargy can also accompany this diagnosis. Inflammation in external part of the ear canal thus refuting this diagnosis (Pontefract et al., 2019).
  3. Eustachian catarrh (Refuted)
    1. Occurs in the middle ear, and results after an upper respiratory infection (Vasudevan & David, 2016). Patient has a no recent upper respiratory tract infection. Refuted
  4. Ramsay Hunt syndrome (Refuted)
    1. Complication of shingles. May present with symptoms of otitis externa, yet has evidence of vesicular eruptions within 2 days of first onset of pain. Pt has no history of shingles, Refuted (Musso & Crews, 2016).
  5. Contact dermatitis (Refuted)
    1. Allergic reaction to materials (e.g., metals, soaps, plastics) in contact with the skin/epithelium; itching is predominant (Schaefer, & Baugh, 2012). Pt has no piercing or known allergic reactions, refuted.
soap note subjective, subjective soap note
soap note subjective, subjective soap note

SOAP NOTE ASSESSMENTExample 2:

Assessment:

Differential Diagnosis:

  1. Herpes Zoster Virus (ICD-9: 053). Rash, pain and eruption of grouped vesicles in the same dermatome and fellow a segment of the body suggests herpes zoster virus. The symptoms described by ABC suggests Herpes Zoster Virus (Dains, Baumann, & Scheibel, 2019)
  2. Herpes Simplex Virus (ICD-9: 054). Prodrome, which can include symptoms, such as fever, malaise, loss of appetite, and localized pain and/or burning at the site the lesions will occur. Tingling and burning without lesions, to recurrent genital ulcerations. Typical widespread lesions clustered together and predilection for lips and genitalia (Dains, Baumann, & Scheibel, 2019). The rash ABC exhibits is not in the area and is on the same dermatome and is likely to be HSV (Kennedy, & Gershon, 2018).
  3. Contact Dermatitis (ICD-9: 692). Localized burning, stinging, itching, blistering, redness, and swelling at the area of contact with the allergen or irritant. ABC was not exposed to an allergen or environmental irritant and does not describe the rash as pruritic (Ball et al., 2019). Soap note nursing example

ASSESSMENT: Herpes Zoster Virus (ICD-9: 053).

soap note plan EXAMPLES
soap note subjective EXAMPLES

SOAP NOTE ASSESSMENT Example 3

ASSESSMENT:

Differential Diagnoses

  1. Hypertension Stage 3 or hypertensive crisis (Confirmed) With a BP of This in and of itself indicates a hypertensive crisis (Pierin et al, 2019). It calls for immediate attention by a physician and therefore the patient has to be admitted. A diastolic value of 107 mmHg is better than the systolic value meaning the physician could classify it has hypertension Stage 2 but since the readings are different (one better and one worse the classification is correct to the one considered worse.
  2. Hypertensive emergency (Refuted) unlike hypertensive urgency which has no associated target organ damage, the patient does not exhibit neurologic, aortic, cardiac, renal, and hematologic damage.
  3. Secondary hypertension due to another underlying medical condition or drug abuse(Refuted) the patient does not report to have any chronic condition other that spinal stenosis that was diagnosed 6 six years ago. It is hypertension that causes chronic neck pain like the one of spondylosis. Neither does the patient report of having any drug or substance issues.

Therefore the patient cannot take part in the study as his assessment points towards Chronic, unregulated hypertension is diagnosed: specifically hypertension urgency.

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.

Takeaways

SOAP Notes are should follow a set structure. Check whether your instructor has included a template for you to use. Otherwise, you can use our guidelines. However, if you don’t have sufficient time, make use of our nursing writers.

Most nurses already have the skills and competence but struggle with getting sufficient time to do nursing assignments. We were born out of the necessity to help out continuing and practice nurses with their nursing assignments, Not because they do not know how to, but to create time for them for other important things like rest, family, and the things that make this life worth living. Let us buy you some time!

soap note plan EXAMPLES
soap note subjective EXAMPLES

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