SOAP Note

With this assignment, you will demonstrate your ability to document a clinical encounter in the widely accepted SOAP note format. The SOAP note will be based on the given clinical case scenario detailed below.

Clinical Case Scenario

Dx: Enuresis

A 7-year-old male presents to your clinic with his mother with a complaint of enuresis. This child has never been completely continent at night, wetting his bed several times per week. This has become somewhat of a problem for him now that his friends are having sleepover birthday parties. His mother confides that she’s tired of paying for pull-ups and cleaning sheets. His incontinence is monosymptomatic (meaning no overactive bladder symptoms or daytime wetting).
Allergies: NKDA

To complete this assignment successfully, you will need to read the assignment instructions and accurately address each criterion.

Assignment Instructions

All SOAP note assignments will follow the format below. Your SOAP note must follow the APA format and should include a title page, in-text citations, and a reference page.

SUBJECTIVE

HPI

Document the information given in the case
Include a list of relevant questions you should ask in order to obtain any missing information
Remember OLD CARTS when completing this task.
ROS

Document any symptoms given in the case
Include a list, per body systems, of ‘classic’ symptoms specific to the given diagnosis.
You may refer to your textbook or other resources to complete this section.
OBJECTIVE

VITAL SIGNS – Include a list the following vital signs that correspond to the age of the presented patient – document what is given and assign a value to what is missing based on age.
Height & Percentile; Weight & Percentile; Temperature; Blood Pressure; Heart Rate; and Respirations

PE

Document any exam findings given in the case
Include a list, per body systems, of the ‘classic’ physical examination findings specific to the given diagnosis.
You may refer to your textbook or other resources to complete this section.
ASSESSMENT

Dx

List the given diagnosis with the ICD-10 code. Include a brief description of the pathophysiology.
List TWO differential diagnosis with their ICD-10 codes. Include a brief description of the pathophysiology and a rationale for the chosen differentials.
PLAN

Labs

Document any lab results presented in the case
List any tests you’d like to ordered – include the reason for the test and what it will show
Plan

Document the information given in the case
Document your treatment and management plan based a National Clinical Guidelines.
You may NOT use your textbook for this; only clinical guidelines
Make sure to include:

Vaccines administered this visit
Medication-amounts and mg/kg for medications
Patient education about the condition including preventive care and anticipatory guidance
Non-medication treatments
Follow-up appointment with detailed plan of f/u
Reflection – Include your thoughts about the given case. What did you learn?