NRNP 6552: Advanced Nurse Practice in Reproductive Health Care
Episodic/Focused SOAP Note Template
Initials, Age, Sex, Race
CC (chief complaint): This is 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 African American female). 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:
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, Naproxen 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 over-the-counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus 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 & Substance Hx: Include occupation and major hobbies, family status, vaping, tobacco and alcohol use (previous and current use, how many times a day, how many years), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.
Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual—current and historical).
Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any sexual concerns.
ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.
GENITOURINARY/REPRODUCTIVE: Burning on urination. Pregnancy. LMP: MM/DD/YYYY. Breast-lumps, pain, discharge? No reports of vaginal discharge, pain?. sexually active?
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
Physical exam: From head to toe, include what you see, hear, and feel when conducting 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:).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
Primay and 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.
Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?
Example. Primary Diagnoses:
1. Chlamydia A74.9: Most common bacterial STI, incubation ranges from 5-14 days for symptomatic disease, the unknown duration for asymptomatic disease. Clinical manifestation of symptoms can be asymptomatic, or in females, can present with genitourinary tract infection, mucopurulent endocervical discharge, easily induced endocervical bleeding, edematous ectopy, and cervicitis; other symptoms are nonspecific (Hsu, 2022).
Given CB’s sexual history and presentation of symptoms (burning, yellow watery discharge, and partner with known chlamydia), I would empirically treat for chlamydia even before receiving test results based on the rules for expedited partner therapy. I would also be suspicious of symptoms of a genitourinary tract infection based on her description of burning and the incidence of C. trachomatis ascending into the urethra (Hsu, 2022).
Differential Diagnoses Differential Diagnosis (DDx):
1. Gonorrhea A54.9: Second most common bacteria causing STI. Gonorrhea is a gram-negative coccus that can cause cervicitis in women. The incubation period is roughly ten days from exposure. Like chlamydia, symptom manifestation typically presents as asymptomatic, but clinical symptoms include vaginal pruritus, mucopurulent discharge, intermenstrual bleeding, or menorrhagia. Physical examination may show frank discharge from the cervix and cervicitis. The first presenting symptom in asymptomatic gonorrhea is PID (Ghanem, 2022). Coinfection with chlamydia occurs in a significant percentage of patients, although presumptive empirically treating for gonorrhea with chlamydia is not routinely warranted without diagnostic testing first (Hsu, 2022). This cannot be ruled out until diagnostic testing is performed and could potentially be a coinfection with chlamydia.
2. Bacterial Vaginosis N77.1: The overgrowth of normal vaginal flora. Clinical manifestations include copious thin vaginal discharge that has a characteristic fish-like odor. Other associated symptoms include dysuria, dyspareunia, and vaginal pruritus. Etiology is likely due to the absence of Lactobacilli species in the vaginal microbiota, which can occur after sexual intercourse, multiple partners, vaginal douching, and recent antibiotic use. Furthermore, the change in the vaginal flora allows for opportunistic STI infections in the future (Kairys & Garg, 2022). This diagnosis can be ruled out as there was no pruritus or white discharge with a fishy or malodor.
3. PID N73.9: Most caused by other STIs such as chlamydia, gonorrhea, and trichomoniasis, symptoms can develop if STI is not treated in a timely manner or go untreated. Manifestation of symptoms includes pelvic pain, abdominal pain, cervicitis, cervical motion, and uterine or adnexal tenderness (Hsu, 2022). While CB is being diagnosed with chlamydia, she does not have any cervical motion, or abdominal or pelvic pain, leading me to believe that while PID isn’t the primary diagnosis, it could have become a complication of chlamydia if she had gone untreated.
1. Antibiotics: According to the rules of expedited partner therapy, you can presumptively treat for chlamydia without testing or before results: Doxycycline 100mg PO BID x 7 days (Hsu, 2022).
2. OTC probiotics daily
3. OTC acetaminophen per label instructions every 4-6 hours PRN for discomfort.
4. OTC ibuprofen per label instructions every 6-8 hours PRN for discomfort.
5. Eat yogurt and other fermented foods to increase good gut bacteria.
6. Abstain from sexual intercourse until both you and your partner are fully treated.
7. Wash any and all toys with warm soap and water or appropriate disinfectant.
Labs: Nucleic acid amplification testing (NAAT) – test of choice for diagnosis (Hsu, 2022). Will obtain via vaginal swab during a pelvic exam. If available, a rapid “Xpert” testing for GC/Chlamydia. I would ask CB if she would like further STI testing, which would include HIV, RPR, HSV, HPV, and Hepatitis B and C (CDC, 2021). The incidence of STIs increases the risk of others. Urinalysis and culture, Urine HCG- all women of childbearing age with chlamydia should be tested for pregnancy (Hsu, 2022). Wet mount – examination to identify bacterial vaginosis, yeast infection, and trichomoniasis (Kairys & Garg).
Consults: None at this time.
Patient Education: Anticipatory guidance was given. Strict return precautions were discussed. Discussed the need for strict adherence to antibiotic therapy. Discussed good hygiene practices and supportive care as indicated. Discussed OCPs do not protect against STIs and the need for additional STI protection and testing. Discussed abstaining from intercourse until antibiotic therapy is completed and symptoms resolved for patient and partner. Expect a call from the health department as chlamydia is a mandated reported condition.
Health Promotion: Good personal hygiene, routine gynecologic exams, including PAP smears and STI screening.
Disease Prevention: Recommend staying up to date with CDC guidelines for vaccinations and annual influenza vaccinations, routine annual visits, Pap Smear and STI screening.
Disposition: Follow up if symptoms worsen or do not improve in the next 72 hours if there is an increase in discharge, a spike in fever, or return of symptoms after treatment. Return in 3 months after treatment completion for repeat screening (Hsu, 2022).
Additional questions I would ask: have the symptoms been the same or have they gotten worse? Has there been any change or improvement in the symptoms? How much vaginal discharge are you seeing? Has the quantity or characteristic of the discharge changed? Have you noticed any foul odors or smelling of fish? Where is the burning sensation coming from? Can you rate your discomfort 0 none- 10 the worst you’ve had. Have you tried anything to resolve or improve the symptoms? Does anything make them worse? Have you had symptoms like this in the past? Do you use condoms or other measures to prevent against STIs? Have you ever had a pelvic/ PAP smear before? Any changes to menses? Any use of vaginal douches or antibiotics? Is there any chance you could be pregnant? When was your LMP? Have you missed any of your birth control pills? When were you last sexually active? Have you had oral or anal intercourse?
Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
© 2022 Walden University, LLC