SOAP Note Format Essay Assignment

SOAP Note Format Essay Assignment

Using a friend, family member, or colleague, perform a detailed men’s health history. Document the history and the expected normal physical examination findings in the SOAP note format.

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Even though your patient may have abnormal findings, you must document the expected normal exam findings for the system. If you would like to include the abnormal findings they should be noted in parenthesis next to the normal expected findings. The complete subjective and objective sections must be included. You may include the assessment and plan portion of the SOAP note, but these sections will not be graded.

You should devise a chief complaint so that you may document the OLDCART (HPI) data. You must use the chief complaint of penile discharge, rectal bleeding, or frequent urination. You should also focus the ROS based on the patient’s chief complaint and the body systems being examined. Refer to the SOAP Note Format document in Course Resources as necessary. This will be the same format that faculty will follow during the immersion weekend.

Nursing Essay Assignments

SOAP Note Format Essay Assignment

For this assignment, I conducted a detailed men’s health history on a friend. The chief complaint provided was “frequent urination.” Below is the SOAP note format documenting the history and the expected normal physical examination findings:

Subjective:
The patient, a 30-year-old male, presents with the chief complaint of frequent urination. The patient reports that he has been experiencing an increased urge to urinate and has to visit the bathroom more often than usual. He denies any pain or discomfort during urination. The patient states that he has been drinking more fluids lately due to his increased physical activity level.

Objective:
General Appearance: The patient appears well-nourished and in no acute distress. He is alert and oriented.

Vital Signs:
– Blood Pressure: 120/80 mmHg
– Heart Rate: 72 beats per minute
– Respiratory Rate: 16 breaths per minute
– Temperature: 98.6°F (oral)

Clinical Reasoning and the Physical Assessment Paper

Skin: The skin is intact and without lesions. No signs of rashes or discoloration.

Head, Eyes, Ears, Nose, Throat (HEENT):
– Head: Normocephalic and atraumatic.
– Eyes: Pupils are equal, round, and reactive to light. Visual acuity is normal.
– Ears: Bilateral canals clear, no signs of discharge.
– Nose: No congestion or discharge.
– Throat: Oropharynx is clear.

Neck: Supple, no lymphadenopathy, and no masses palpated.

Chest and Lungs: Clear breath sounds bilaterally, no wheezes or crackles.

Heart: Regular rate and rhythm, no murmurs or extra heart sounds.

Abdomen: Soft, non-tender, and non-distended. Bowel sounds present in all quadrants.

Genital/Rectal: External genitalia without lesions or masses. No penile discharge reported. Digital rectal examination not performed.

Musculoskeletal: Full range of motion in all extremities. No joint deformities or tenderness.

Neurological: Alert and oriented to person, place, and time. Cranial nerves intact.

Assessment and Plan:
No assessment or plan is provided as per assignment instructions.

In conclusion, the patient’s chief complaint of frequent urination was addressed through a detailed history and examination. Expected normal findings were documented for various body systems based on the chief complaint. Abnormal findings were not reported in this exercise.