Urinary Tract Infection SOAP Note

Urinary tract infection SOAP note

Delete all text in red - these are instructions and not part of the SOAP document.

SOAP Note Genitourinary: urinary tract infection

Requirement:

APA format

Intext citation

References at least 4 high-level scholarly reference per post within the last 5 years in APA format.

EACH differential diagnostic gets 1 reference and the Treatment

Plagiarism free.

Turnitin receipt.

ID:

Client’s Initials*Age__76___ Race________Gender__Male__________Date of Birth___________

Insurance _______________ Marital Status_____________

Subjective:

CC: “low back pain and urge to urinate”

HPI:

In paragraph format, including at the minimum OLDCARTS. Please start with demographics: AA, a 29 y.o. Asian female presents to the clinic alone with complaint of _____________.

Onset, Location, Duration, Characteristics/context, Aggravating factors or Associated symptoms, Relieving Factors, Treatment, and Timing, Severity. Include any pertinent positives or negatives.

Past Medical History:

· Medical problem list

· Preventative care: (if applicable to the case - Paps, mammography, colonoscopy, dates of last visits, etc.)

· Surgeries:

· Hospitalizations:

· LMP, pregnancy status, menopause, etc. for women

Allergies:

Food, drug, environmental

Medications: include names, doses, frequency, and routes, and reason in parenthesis if off-label or secondary use

Family History:

Social History:

-Sexual history and contraception/protection (as applies to the case)

-Chemical history (tobacco/alcohol/drugs) (ask every pt about tobacco use)

Other: -Other social history as applicable to each case (diet/exercise, spirituality, school/work, living arrangements, developmental history, birth history, breastfeeding, ADLs, advanced directives, etc. Exercise your critical thinking here - what is pertinent and necessary for safe and holistic care)

ROS (write out by system): Comprehensive ( >10) ROS systems for wellness exams or complex cases only. Do not include all 14 systems for every SOAP unless needed - review and document the pertinent systems. Do not include diagnoses - those belong in PMH. The below categories are per CMS guidelines.

Constitutional:

Eyes:

Ears/Nose/Mouth/Throat:

Cardiovascular:

Pulmonary:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Integumentary & breast:

Neurological:

Psychiatric:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

Objective

Vital Signs: HR BP Temp RR SpO2 Pain

Height Weight BMI (be sure to include percentiles for peds)

Labs, radiology or other pertinent studies: be sure to include the date of labs - might be POC tests from today

Physical Exam (write out by system):

Assessment

(you will often have more than one diagnosis/problem, but do the differential on the main problem)

Differentials (with a brief rationale and references for each one:

1. Urinary tract infection:

2. Benign prostatic hyperplasia:

3. Prostate cancer:

Diagnosis: Urinary Tract Infection

Plan (4 pronged-plan for each problem on the problem list)

Diagnostics: Urinary tract infection

Treatment: (please use Guidelines reference)

Education:

Follow Up:

List plan under each Diagnosis.

Example

1: Hypertension (I10)

A: Lisinopril/HCT 20/12.5 Daily #90, refills 3

B: BMP in 6 months

C: Recheck BP in 2 Weeks

D: Low Sodium Diet and lifestyle modifications discussed

2: Morbid Obesity BMI XX.X (E66.01)

A: Goal of 5% weight reduction in 3 months

B: Increase exercise by walking 30 minutes each day

C: Portion Size Education

3: T2 Diabetes with diabetic neuropathy (E11.21)

A: Repeat A1C in 3 months

B. Increase Metformin to 1000mg BID #180, refills: 3

C: Annual referral to diabetic educator, ophthalmology, and podiatry (placed X/X)

D: Daily blood glucose check in the am and when sick

E. Return to clinic in 3-4 months to reassess