soap note rewrite

Order Description

this note is missing important subjective, objective, and reflection to provide a substantive note. PLEASE FOLLOW ATTACHMENT AND EDIT WHAT IS REQUIRED BY THE PROFESSOR. THANKS THIS PAPER WAS WRITTEN BY ONE OF YOUR WRITER BUT DID NOT MAKE A 50 AND PROFESSOR DEMANDED FOR A REWRITE.
Date: 10/26/2016
Chief Complaint: “I have nausea for last 2 weeks.”
History of Present Illness: M.P is a 28-year-old African American female, who came up to the clinic 2 weeks ago with a complaint of having a very bad discharge from the vagina. The patient informed me that she was single mother recently divorced and she was three months pregnant. She has several sexual partners and sometimes she does not use protection during intercourse. She has one child which she delivered through C-section due to complications.

Medications: None
Allergies: NKDA
Past Medical History: None
Past Surgical History: Previous C-section.
Personal/Social History: graduated high-school, reclusive social life. She came from broken family. The patient drinks once or twice a week. She has several sexual partners and sometimes she does not use protection during intercourse.
Immunizations: Up to date with immunization.
Family History: None
General: Healthy sleeping-cycle recently reduced to 4-5 hours due to vaginal itching.
HEENT: The Healthy Respiration , denies epistaxis.
Respiratory: No problem reported .
Cardiovascular: Denies any pain in the cardiac region.
Urinary: Is positive about a healthy urinary track . She complained of having a very bad discharge from the vagina.
Gastrointestinal: denies diarrhea or pattern change in Bowel movement
Musculoskeletal: Denies any restriction in Range of Motion.
Endocrine : Denies any problems .
Objective Data:
I observed that she had shaved all her genital hair completely. I also observed grayish yellow smelly vaginal discharge. Her breasts were tender and abnormal virginal itching. The uterus was smooth and within the normal limits.

Vital Signs: B/P: 109/68; HR 72, T 98.6 F orally; RR 18; non-labored; Wt: 115 lbs; Ht: 5’5’’, BMI 18.0.
Neuro: Patient is responsive and follows command.
Skin: Patient skin is warm and intact.
HEENT: EOMI is clear, Adequate hearing, with the tympanic membrane gray and intact. No head trauma; PEERLA, white sclera, pink conjunctiva. No loss of hearing, tinnitus or vertigo. No epistaxis, congestion, rhinorrhea, and sneezing present. No dysphagia, voice change, bleeding gums, slight throat sore .

NECK: No injury, pain or fracture.
Chest/Lungs: Bilaterally and equal..
Heart/Peripheral Vascular: S1 S2. RRR, no gallops, no murmurs.
Abdomen: Abdomen soft, flat, non-tender. +BS in all quadrants.
Musculoskeletal: Equal movement to all extremities .
Assessment:
Acute Diagnosis:
My primary diagnosis was Bacterial Vaginosis. This is because, the symptoms, the pelvic exam and the tests done on the vaginal sample reveal that indeed it is bacterial vaginosis (Parker, Parker & Parker, Philip 2007).

Differential diagnoses: As far as assessment is concerned, my differential diagnosis consisted of Trichomoniasis, Gonorrhea, and Chlamydia .
Plan:
My plan for diagnosis and primary diagnosis included microscopic examination of the discharge. A phP.H greater than 4.5 strongly indicates infection and for patients with bacterial vaginosis, phPH may be raised up to ninety percent (Parker, Parker & Parker, Philip 2007).
As far as my plan for treatment and management is concerned, I recommended Flagyl 500 mg bid for 1 week for bBacterial vVaginosis. I also advised the patient to stop douching or using over the counter vaginal hygiene products. I also booked her for therapy sessions so that she can be counseled on some of the risky sexual behaviors that she used to engage in like having unprotected sex with several partners (Parker, Parker & Parker, Philip 2007 ). In a similar patient evaluation, I would collect more subjective information since I found out that it contributes a lot to the diagnosis.

Reflection Notes:
Compelling into account my experience for the past 11 years, and monitoring the patient’s symptoms, I am assertive the patient will improve within a week time.
References
Parker, J. N., Parker, P. M., & Parker, Philip M. (2007). The Official Patient’s Sourcebook on Bacterial Vaginosis. ICON Group.
Schuiling, K. D., & Likis, F. E. (2006). Women’s gynecologic health. Sudbury, Mass: Jones and Bartlett.
Women’s Health SOAP Note Evaluation Criteria

Each SOAP Note is worth 100 points. The original grading criteria have been modified to make it clear how points would be allocated. The point allocation for each major category was not altered.
SOAP Notes should reflect new experiences related to your practicum experiences in this course. Your submissions should be your original work and cannot be repurposed from previous courses.
Your SOAP Note should be based on an individual patient and address the following:
• Subjective: Details the patient provided regarding his or her personal and medical history (15 points)
• How points will be allocated
• CC (1 point)
• Pertinent negatives (from ROS), PMH, SH, & FH (6 Points)
The OBGYN history
1. Chief complaint
2. History of present illness
3. Menstrual history
1. Age at menarche
2. Last menstrual period
3. Menstrual pattern
1. Cycle length
2. Duration of flow
3. Amount of flow
4. Associated pain (dysmenorrhea, mittelschmerz)
5. Intermenstrual bleeding
4. Perimenopause/menopause
1. Bleeding pattern
2. Vasomotor symptoms
3. Hormone replacement therapy
4. Contraception
1. Current method; satisfied with method?
2. Previous methods, including complications, reasons discontinued
5. Cervical and vaginal cytology
1. Most recent Pap smear result
2. History of abnormal Pap smears? If so, nature of diagnosis, treatment, and follow-up
6. Infection
1. History of sexually transmitted infections
2. History of vaginitis, including types, frequency, and treatment
3. History of pelvic inflammatory disease
7. Fertility/infertility
1. Desire for future fertility
2. Any difficulty conceiving in past? If so, prior evaluation and treatments
8. Sexual history
1. Type
2. Concerns about libido, dyspareunia, or orgasm?
3. History of sexual abuse or sexual assault?
9. Obstetric history
1. Describe each pregnancy and the outcome. GPTAL
2. Describe any maternal, fetal, or neonatal complications
10. Past medical history
1. Current or past illnesses
2. Hospitalizations
11. Past surgical history
1. Past gynecologic surgeries
2. Past nongynecologic surgeries
12. Medications and allergies
1. Prescribed medications
2. Over-the-counter medications
3. Herbal preparations
4. Allergies to medications and nature of reactions
13. Family history
1. Significant illnesses of family members
2. Known hereditary conditions in family
14. Social history
1. Marital or relationship status
2. Level of education
3. Occupation
15. Review of systems
1. Abdomino-pelvic
1. Gynecologic
2. Urinary
3. Gastrointestinal
2. Breast
3. Other
16. Health maintenance
1. Tobacco, alcohol, illicit drug use
2. Diet
3. Calcium and folate intake
4. Exercise
5. Use of seatbelts, helmets, sunscreen, smoke detectors
6. Firearms in the home?
7. Dates and results of screening tests such as mammography, sigmoidoscopy or colonoscopy, bone densitometry, lipid analysis, glucose and thyroid testing
8. Immunizations and dates administered
• Medications and drug/food allergies are not included (1 point)

• Objective: Observations that you make during the physical assessment (15 points)
• How points will be allocated
• VS including FHT if indicated (2 points)
• Thyroid, Heart, and lungs (1 point)
• Systems or specialty exam techniques that are not necessary to arrive at a diagnosis are included. (-1 for each up to 5 points)
• Systems or specialty exam techniques that are necessary to arrive at your diagnosis are omitted. (-1 for each up to 5 points)
• Diagnostic test results (2 points) – (ex; BHCG, CBC, Rubella, RPR, pap, GC, CT, 1 HR GTT, GC/CT, urine dip, wet prep, Blood group & RH Status)

• Assessment: Need to list your priority diagnosis first. For each priority diagnosis, if possible list at least 3 differential diagnoses. (30 points – 10 points for each priority diagnosis. If less than 3 are appropriate to include – simply no other diagnoses to consider – you will receive all 30 points. Please do not “stretch” to find 3 if they are not actual possibilities.
Examples: Intrauterine Pregnancy (IUP) at 8 weeks, Contraceptive Counseling, desires copper IUD

• Plan: Your plan for diagnostics and primary diagnosis; and your plan for treatment and management including alternative therapies. (15 points)
Because not all items listed below may be appropriate for your plan, if you include what is appropriate, you will receive the points. However, if one of the items that should have been included was not, points associated with each item will be deducted.
• Pharmacological and non-pharmacological strategies
• Medications discontinued (“d/c lisinopril 10 mg daily”) (1 point)
• Medications started (“start Avapro 150 mg daily”) (2 points)
• Alternative therapies if appropriate (1 point)
• Health Promotion strategies – patient/family education (3 points)
• Disease Prevention strategies with timeframe if appropriate (3 points)
• Diagnostic tests ordered with timeframe (now, in 2 weeks, prior to f/u visit in 3 months) (3 points)
• Referrals or consultations if appropriate (1 point)
• Follow-up interval (1 point)

• Reflection notes: What you would do differently in a similar patient evaluation (25 points)
Address each point even if you have nothing specific to add. For example, if you would have done nothing differently, say so and include why. If you fail to mention one of these items, you will lose the points associated with it.
• What did you learn from this experience? Any ah-ha’s? (5 points)
• What would you do differently? (5 points)
• What additional data would you have gathered? (5 points)
• What additional elements of the exam would you have done? (5 points)
• Do you agree with your preceptor based on the evidence? (5 points)
Sources of support for your analysis may include your Learning Resources (texts, articles, videos), but should also include evidence-based information from national guidelines or journal articles in nursing and other professional literature. Use these sources to support the observations and conclusions that you reach, and cite them in the appropriate place in your SOAP Note. Include a minimum of two peer-reviewed journal articles along with other sources. The goal is to analyze what you observed and relate it to evidence-based practice.
Formatting: It is understood that you will be using incomplete sentences in the actual SOAP note. However, please use punctuation effectively, using a semi-colon or period to alert the reader that you are changing topics. Your assessment and plan should maintain the SOAP format. References in APA format must be included for items in the plan. Points may be deducted if this does not occur.
SOAP note rubric

Subjective (15 points)13.5 Points Possible Points Earned
• CC 1 1
• Pertinent positives (OLDCARTS) 5 NA/5
• Pertinent negatives & positives (from ROS) 5 2.5 Did not include pertinent GI and GU symptoms5
• Pertinent PMH, SH, and FH 3 3
• Medications and drug/food allergies are included 1 1
Objective (15 points)10
• VS including FHT if indicated 3 3
• Thyroid, Heart, and Lungs 1 1
• Systems or specialty exam techniques that are not necessary to arrive at a diagnosis are included. -5 5
• Systems or specialty exam techniques that are necessary to arrive at your diagnosis are omitted. -5 0 Did not include a pelvic exam for diagnosis of bacterial vaginosis5
• Diagnostic test results (ex; BHCG, CBC, Rubella, RPR, pap, GC, CT, 1 HR GTT, GC/CT, urine dip, wet prep, Blood group & RH Status) 2 2
Assessment (10 points for each priority diagnosis to equal 30)15 30 15 did not address the pathology of the differential diagnoses30
Plan (15 points)15
• Medications discontinued (“d/c lisinopril 10 mg daily”) 1 NA/1
• Medications started (“start Ferrous Sulfate 325 mg daily”) 2 2
• Alternative therapies if appropriate (1 point) 1 NA/1
• Diagnostic tests ordered with timeframe 6 6
• Referrals or consultations if appropriate 2 2
• Follow-up interval 3 3
Reflection notes (25 points)10
• What did you learn from this experience? Any ah-ha’s? (5 points) 5 0 Did not mention5
• What would you do differently? 5 5
• What additional data would you have gathered? 5 5
• What additional elements of the exam would you have done? 5 0 Did not mention5
• Do you agree with your preceptor based on the evidence? 5 Did not mention5
Chidinma, this note is missing important subjective, objective, and reflection to provide a substantive note. Total points 100 63.5100