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Samuel Merritt University Nursing Vaginal Discharge SOAP Notes
CC: 16 year old female c/o of vaginal discharge X 3 days.
LMP- 2 weeks ago, currently sexually active with multiple partners and not using any birth control method. Smokes 10 cigs a day with marijuana on weekends.
1.Write a hypothetical SOAP note based on the above chief complain.
2. How would you use mnemonic HEEADSSS in history taking with this patient.
3. Document external, internal, bimanual, and rectovaginal PE findings on your SOAP note( See Seidel’s guide page 472, sample documentation).
4. Document Wet Mount result including normal saline and KOH preparation on your SOAP note( See Seidel’s guide page 457).
5. Write a substantive response to a minimum of two different students. Is objective and subjective data included in the right format? Please be specific to information related to the SOAP note format.
- Would you agree with your peers differentials listed? Are there any diffs you would add/remove, if so explain your rationale.
- Does HPI have relevant information related to CC?
- Medication listed with right timing, dosing, and number of tablets specified? Any red flags with medication list?
- PMH, FH, and SH has all the appropriate information?
- Does information in ROS correlate to CC?
- Is there any information lacking in physical exam documentation of CC (Students often get confused between ROS and objective findings)?
- Includes assessment, plan, follow up information, and patient education?
See sample SOAP Note: Sample_ SOAP_ Note
20 points will be deducted for combining subjective and objective information. Please see example below:
ROS:
Example 1.
General: Alert and oriented, denies fatigue and chills.
( subjective and objective information is combined above. ” Alert and oriented” is part of PE general and not ROS.
Example 2.
ROS:
Resp: denies cough, wheezing, lungs sounds CTA bilaterally.
( subjective and objective is combined above;” lungs sounds CTA bilaterally” is part of PE
PE:
Example 1:
PE: Denies fatigue and chills. Alert and oriented.
” Denies fatigue and chills” is part of ROS and not PE.
Example 2:
PE: Bowel sounds present all quadrants. Denies abdominal pain.
” Denies abdominal pain” is part of ROS and not PE
