NR509 Shadow Health SOAP Note Template
SOAP Note Template
S:
Subjective
Information the patient or patient representative told you
SOAP Note Template
Initials: Click or tap here to enter text.
Age: Click or tap here to enter text.
Gender: Click or tap here to enter text.
Height
Weight
BP
HR
RR
Temp
SPO2
Pain
Allergies
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Medication: Click or tap here to enter text.
Food: Click or tap here to enter text.
Environment: Click or tap here to enter text.
History of Present Illness (HPI) NR509 Shadow Health SOAP Note Template
Chief Complaint (CC)
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CC 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”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom
O
nset
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L
ocation
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D
uration
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C
haracteristics
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A
ggravating
Factors
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R
elieving Factors
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T
reatment
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Current Medications:
Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication
(Rx, OTC, or Homeopathic)
Dosage
Frequency
Length of Time Used
Reason for Use
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Past Medical History (PMHx) –
Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed.
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Social History (Soc Hx) –
Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
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Family History (Fam Hx) –
Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
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Review of Systems
(ROS):
Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details.
Constitutional
Skin
HEENT
☐Fatigue Click or tap here to enter text.
☐Weakness Click or tap here to enter text.
☐Fever/Chills Click or tap here to enter text.
☐Weight Gain Click or tap here to enter text.
☐Weight Loss Click or tap here to enter text.
☐Trouble Sleeping Click or tap here to enter text.
☐Night Sweats Click or tap here to enter text.
☐Other:
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☐Itching Click or tap here to enter text.
☐Rashes Click or tap here to enter text.
☐Nail Changes Click or tap here to enter text.
☐Skin Color Changes Click or tap here to enter text.
☐Other:
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☐Diplopia Click or tap here to enter text.
☐Eye Pain Click or tap here to enter text.
☐Eye redness Click or tap here to enter text.
☐Vision changes Click or tap here to enter text.
☐Photophobia Click or tap here to enter text.
☐Eye discharge Click or tap here to enter text.
☐Earache Click or tap here to enter text.
☐Tinnitus Click or tap here to enter text.
☐Epistaxis Click or tap here to enter text.
☐Vertigo Click or tap here to enter text.
☐Hearing Changes Click or tap here to enter text.
☐Hoarseness Click or tap here to enter text.
☐Oral Ulcers Click or tap here to enter text.
☐Sore Throat Click or tap here to enter text.
☐Congestion Click or tap here to enter text.
☐Rhinorrhea Click or tap here to enter text.
☐Other:
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Respiratory
Neuro
Cardiovascular
☐Cough Click or tap here to enter text.
☐Hemoptysis Click or tap here to enter text.
☐Dyspnea Click or tap here to enter text.
☐Wheezing Click or tap here to enter text.
☐Pain on Inspiration Click or tap here to enter text.
☐Sputum Production
Choose an item.
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☐Other: Click or tap here to enter text.
☐Syncope or Lightheadedness Click or tap here to enter text.
☐Headache Click or tap here to enter text.
☐Numbness Click or tap here to enter text.
☐Tingling Click or tap here to enter text.
☐Sensation Changes
Choose an item.
☐Speech Deficits Click or tap here to enter text.
☐Other: Click or tap here to enter text.
☐Chest pain Click or tap here to enter text.
☐SOB Click or tap here to enter text.
☐Exercise Intolerance Click or tap here to enter text.
☐Orthopnea Click or tap here to enter text.
☐Edema Click or tap here to enter text.
☐Murmurs Click or tap here to enter text.
☐Palpitations Click or tap here to enter text.
☐Faintness Click or tap here to enter text.
☐OC Changes Click or tap here to enter text.
☐Claudications Click or tap here to enter text.
☐PND Click or tap here to enter text.
☐Other: Click or tap here to enter text.
MSK
GI
GU
PSYCH
☐Pain Click or tap here to enter text.
☐Stiffness Click or tap here to enter text.
☐Crepitus Click or tap here to enter text.
☐Swelling Click or tap here to enter text.
☐Limited ROM Choose an item.
☐Redness Click or tap here to enter text.
☐Misalignment Click or tap here to enter text.
☐Other: Click or tap here to enter text.
☐Nausea/Vomiting Click or tap here to enter text.
☐Dysphasia Click or tap here to enter text.
☐Diarrhea Click or tap here to enter text.
☐Appetite Change Click or tap here to enter text.
☐Heartburn Click or tap here to enter text.
☐Blood in Stool Click or tap here to enter text.
☐Abdominal Pain Click or tap here to enter text.
☐Excessive Flatus Click or tap here to enter text.
☐Food Intolerance Click or tap here to enter text.
☐Rectal Bleeding Click or tap here to enter text.
☐Other:
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☐Urgency Click or tap here to enter text.
☐Dysuria Click or tap here to enter text.
☐Burning Click or tap here to enter text.
☐Hematuria Click or tap here to enter text.
☐Polyuria Click or tap here to enter text.
☐Nocturia Click or tap here to enter text.
☐Incontinence Click or tap here to enter text.
☐Other: Click or tap here to enter text.
☐Stress Click or tap here to enter text.
☐Anxiety Click or tap here to enter text.
☐Depression Click or tap here to enter text.
☐Suicidal/Homicidal Ideation Click or tap here to enter text.
☐Memory Deficits Click or tap here to enter text.
☐Mood Changes Click or tap here to enter text.
☐Trouble Concentrating Click or tap here to enter text.
☐Other: Click or tap here to enter text.
GYN
☐Rash Click or tap here to enter text.
☐Discharge Click or tap here to enter text.
☐Itching Click or tap here to enter text.
☐Irregular Menses Click or tap here to enter text.
☐Dysmenorrhea Click or tap here to enter text.
☐Foul Odor Click or tap here to enter text.
☐Amenorrhea Click or tap here to enter text.
☐LMP: Click or tap here to enter text.
☐Contraception Click or tap here to enter text.
☐Other:Click or tap here to enter text.
Body System
Positive Findings
Negative Findings
General
Choose an item.
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Skin
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HEENT
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Respiratory
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Neuro
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Cardiovascular
Choose an item.
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Musculoskeletal
Choose an item.
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Gastrointestinal
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Genitourinary
Choose an item.
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Psychiatric
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Gynecological
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Problem List
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A: Assessment
Medical Diagnoses. Provide 3 differential diagnoses which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to support each diagnosis.
Diagnosis
ICD-10 Code
Pertinent Findings
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P:
Plan
Address all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this time” but do not leave any heading blank. No intervention is self-evident. Provide a rationale and evidence-based in-text citation for each intervention.
Diagnostics:
List tests you will order this visit
Test
Rationale/Citation
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Medications:
List medications/treatments including OTC drugs you will order and “continue previous meds” if pertinent.
Drug
Dosage
Length of Treatment
Rationale/Citation
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Referral/Consults: NR509 Shadow Health SOAP Note Template
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Rationale/Citation
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Education:
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Rationale/Citation
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Follow Up:
Indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere.
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Rationale/Citation
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References
Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting.
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Shadow Health Assessment Assignment
You will complete all assessment assignments using the
Shadow Health
virtual reality simulation platform.
Introduction and Pre-brief
Two days after a minor, low-speed car accident in which Tina Jones was a passenger, she noticed daily bilateral headaches along with neck stiffness. She reports that it hurts to move her neck, and she believes her neck might be swollen. She did not lose consciousness in the accident and denies changes in level of consciousness since that time. She states that she gets a headache every day that lasts approximately 1-2 hours. She occasionally takes 650 mg of over the counter Tylenol with relief of the pain. This case study will allow you the opportunity to examine the patient’s optic nerve via use of the ophthalmoscope as well as assess her visual acuity. You will need to document your findings using appropriate medical terminology. Careful assessment of documentation of EACH cranial nerve is integral to performing a comprehensive neurological assessment. Be sure to assess for foot neuropathy using the monofilament test. NR509 Shadow Health SOAP Note Template
Tips and Tricks
By now you are very familiar and comfortable with navigating the Shadow Health virtual learning environment. The simulated patients are similar to actual patients and can respond to over 70,000 initial and follow-up questions. Your patients will never get frustrated when you ask multiple questions and they will never get embarrassed or withhold information if you address sensitive subjects, like sexual activity.
Be sure to practice asking interview questions in Shadow Health using the talk-to-text feature and the Google Chrome browser. This will assist with reducing the time commitment for each assignment and enhance the fidelity of your patient-provider experience.
When writing up your physical examination findings, it is insufficient to simply document that the cranial nerve assessed was “intact” or “normal”. What does this mean? Document exactly what you assessed and the findings. Documentation of pertinent negative findings, which denote what you expect to find during the examination and not an abnormality, are just as important as pertinent positive, or abnormal, findings.
Purposes
The purposes of the Shadow Health Physical Assessment Assignments are to: (a) increase knowledge and understanding of advanced practice physical assessment skills and techniques, (b) conduct focused and comprehensive histories and physical assessments for various patient populations, (c) adapt or modify your physical assessment skills and techniques to suit the individual needs of the patient, (d) apply assessment skills and techniques to gather subjective and objective data, (e) differentiate normal from abnormal physical examination findings, (f) summarize, organize, and appropriately document findings using correct professional terminology, (g) practice developing primary and differential diagnoses, (h) practice creating treatment plans which include diagnostics, medication, education, consultation/referral, and follow-up planning; and (i) analyze and reflect on own performance to gain insight and foster knowledge NR509 Shadow Health SOAP Note Template.
Due Date
Sunday 11:59 PM MT
at the end of
each respective week.
Students are expected to submit assignments by the time they are due. Assignments submitted after the due date and time will receive a deduction of 10% of the total points possible for that assignment for each day the assignment is late. Assignments will be accepted, with penalty as described, up to a maximum of three days late, after which point a zero will be recorded for the assignment.
In the event of an emergency that prevents timely submission of an assignment, students may petition their instructor for a waiver of the late submission grade reduction. The instructor will review the student’s rationale for the request and make a determination based on the merits of the student’s appeal. Consideration of the student’s total course performance to date will be a contributing factor in the determination. Students should continue to attend class, actively participate, and complete other assignments while the appeal is pending.
Total Points Possible: 75 Points
Assignment
Step One: Complete the designated Shadow Health (SH) Assignment on the SH platform.
Step Two: Document your findings on the
Fillable Soap Note Template
or the
Printable Soap Note
.
Step Three: Upload the Lab Pass and completed SOAP Note as separate documents to the same assignment tab in the gradebook.
Requirements
NOTE: Before initiating any activity in Shadow Health, complete the required course weekly
readings and lessons
as well as review the
introduction and pre-brief.
Complete the Shadow Health Concept Lab (Weeks 2, 4, and 5) prior to beginning the graded assignment.
Gather subjective and objective data by completing a focused, detailed health history and physical examination for each physical assessment assignment.
Critically appraise the findings as normal or abnormal. NR509 Shadow Health SOAP Note Template
Complete the post activity assessment questions for each assignment .
Complete all reflection questions following each physical assessment assignment.
Digital Clinical Experience (DCE) scores do not round up. For example, a DCE score of 92.99 is a 92, not a 93.
You have a maximum of two (2) attempts per Shadow Health assignment to improve your performance. However, you may elect not to repeat any assignment. NOTE: If you repeat an attempt, ONLY the second attempt will be graded, regardless of the DCE score. Please refer to the grading rubric categories for details.
Download the Lab Pass for the final attempt on the assignment.
On the Canvas Platform:
Summarize, organize, and appropriately document findings using correct professional terminology on the SOAP Note Template.
Identify three (3) differential diagnoses and provide ICD-10 codes and pertinent positive and negative findings for each diagnosis.
Create a comprehensive treatment plan for each assignment. Must address the following components: Diagnostics, Medication, Education, Referral/Consultation, and Follow-up planning. If no interventions for one or more component, document “none at this time” but do not skip over the component.
Provide rationales and citations for diagnoses and interventions. NR509 Shadow Health SOAP Note Template
Include at least one scholarly source to support diagnoses and treatment interventions with rationales and references on the SOAP note. Only scholarly sources are acceptable for citation and reference in this course. These include peer-reviewed publications, government reports, or sources written by a professional or scholar in the field. The textbooks and lessons are NOT considered to be outside scholarly sources. For the threaded discussions and reflection posts, reputable internet sources such as websites by government agencies (URL ends in .gov) and respected organizations (often ends in .org) can be counted as scholarly sources. The best outside scholarly source to use is a peer-reviewed nursing journal. You are encouraged to use the Chamberlain library and search one of the available databases for a peer-reviewed journal article. The following sources should not be used: Wikipedia, Wikis, or blogs. These websites are not considered scholarly as anyone can add to these. Please be aware that .com websites can vary in scholarship and quality. For example, the American Heart Association is a .com site with scholarship and quality. Each student is responsible for determining the scholarship and quality of any .com site. Ask your instructor before using any site if you are unsure. Points will be deducted from the rubric if the site does not demonstrate scholarship or quality. Current outside scholarly sources must be published with the last 5 years. Instructor permission must be obtained BEFORE the assignment is due if using a source that is older than 5 years.
Upload the Lab Pass to the appropriate assignment area in Canvas Grades
Shadow Health Grading Rubric
Portions of the rubric are designated with a ***. The following explains those portions of the rubric:
*
Digital Clinical Experience (DCE) Score
is automatically translated by Shadow Health based on individual student performance and reflects how student work compares to their peer learners across the country for a particular assignment. The DCE Score is a fair assessment of effort, and therefore is appropriate for use when grading assignments.
**Scholarly Sources:
Only scholarly sources are acceptable for citation and reference in this course. These include peer-reviewed publications, government reports, or sources written by a professional or scholar in the field. The textbooks and lessons are
NOT
considered to be outside scholarly sources. For the threaded discussions and reflection posts, reputable internet sources such as websites by government agencies (URL ends in .gov) and respected organizations (often ends in .org) can be counted as scholarly sources. The best outside scholarly source to use is a peer-reviewed nursing journal. You are encouraged to use the Chamberlain library and search one of the available databases for a peer-reviewed journal article. The following sources should not be used: Wikipedia, Wikis, or blogs. These websites are not considered scholarly as anyone can add to these. Please be aware that .com websites can vary in scholarship and quality. For example, the American Heart Association is a .com site with scholarship and quality. Each student is responsible for determining the scholarship and quality of any .com site. Ask your instructor before using any site if you are unsure. Points will be deducted from the rubric if the site does not demonstrate scholarship or quality. Current outside scholarly sources must be published with the last 5 years. Instructor permission must be obtained BEFORE the assignment is due if using a source that is older than 5 years. NR509 Shadow Health SOAP Note Template
***
Components of a treatment plan include
diagnostics
,
medication
,
education
,
consultation/referral
, and
follow-up planning
****Insight
refers to the capacity to gain an accurate and deep intuitive understanding of a concept or thing. For example, one might demonstrate insight by relating a concept to a personal or meaningful experience.
ASSIGNMENT CONTENT
Category
Points
%
Description
Health History Communication, Education, Empathy, and Summary
(DCE Score
or transcript)
15
20%
The Digital Clinical Experience (DCE) Score is automatically translates by Shadow Health based on individual student performance and reflects how student work with data collection, health history communication, education, empathy, and summarization compares to peer learners across the country for a particular assignment. The DCE Score is a fair assessment of effort, and therefore is appropriate for use when grading assignments. Occasionally, performance transcripts may be reviewed for secondary support.
Assessment, Documentation, Treatment Plan, and Scholarly Sources
35
47%
This category is evaluated on the quality of student’s ability to: Identify pertinent normal and abnormal findings for the assignment, utilize professional terminology, provide comprehensive and detailed subjective and objective findings, identify differential diagnoses, and create a comprehensive treatment plan. Include at least one appropriate EBP scholarly source and use the SOAP Note format template to document all findings.
Self-Reflection
15
20%
Self-reflection posts must demonstrate the student’s own perspective. The quality of this criterion is based upon responding to all the reflection questions; providing responses that are substantive (add importance, meaningfulness, and relevance to the post); demonstrate analysis of own performance; and demonstrate insight. Insight refers to the capacity to gain an accurate and deep intuitive understanding of a concept or thing. For example, one might demonstrate insight by relating a concept to a personal or meaningful experience. Reflection post responses should vary from SH assignment to assignment.
65
87%
Total CONTENT Points= 65
ASSIGNMENT FORMAT
Category
Points
%
Description
Grammar, Spelling, Syntax, Mechanics and APA Format
10
13%
Reflection post has minimal grammar, spelling, syntax, punctuation and APA* errors. Direct quotes (if used) is limited to 1 short statement** which adds substantively to the post.
* APA style references and in text citations are required; however, there are no deductions for errors in indentation or spacing of references. All elements of the reference otherwise must be included.
**Direct quote should not to exceed 15 words & must add substantively to the assignment
10
100%
Total FORMAT Points= 10
ASSIGNMENT TOTAL=
75 points
Rubric
NR509 Weeks 2-6 Shadow Health Assignment_Sept19 (2)
NR509 Weeks 2-6 Shadow Health Assignment_Sept19 (2)
Criteria
Ratings
Pts
This criterion is linked to a Learning OutcomeAssignment Content Possible Points = 65 Points
Criterion 1
Health History Communication, Education, Empathy, and Summary
(DCE Score or Transcript)
15.0 pts
Excellent
DCE Score > 93
14.0 pts
V. Good
DCE Score 86-92
12.0 pts
Satisfactory
DCE Score 80-85
8.0 pts
Needs Improvement
DCE Score < 79
0.0 pts
Unsatisfactory
No Assignment
15.0 pts
This criterion is linked to a Learning OutcomeCriterion 2 Assessment, Documentation, Treatment Plan, and Scholarly Sources
Must demonstrate the following elements:
NR509 Shadow Health SOAP Note Template
Identified all pertinent normal and abnormal findings;
Used professional terminology;
Subjective and objective documentation was detailed and comprehensive;
Used the SOAP Note Format template for documentation;
Identified three (3) differential diagnoses with ICD-10 codes and pertinent positive/negative findings;
Addressed each of the following on the treatment plan: Diagnostics, Medication, Education, Referral/Consultation, and Follow-up Planning;
Interventions are detailed and appropriate for the focused assignment;
Provided at least one appropriate EBP scholar source
(8 Required Elements)
35.0 pts
Excellent
Demonstrated all elements for this Criterion
32.0 pts
V. Good
Missing 1 element for this Criterion
29.0 pts
Satisfactory
Missing 2 or 3 elements for this Criterion
18.0 pts
Needs Improvement
Missing 4 or 5 elements on for this Criterion
0.0 pts
Unsatisfactory
Missing 6 or more elements for the criterion Or No Assignment
35.0 pts
This criterion is linked to a Learning OutcomeCriterion 3 Self-Reflection
Must demonstrate the following elements:
Written from the student’s own perspective;
Responded to all the reflection questions;
Responses were each substantive (added importance, meaningfulness, and relevance to the post);
Offer self-analysis of performance and insight;
Reflection post responses should vary from SH assignment to assignment.
(5 Required Elements)
15.0 pts
Excellent
Demonstrated all elements for this Criterion
14.0 pts
V. Good
Missing 1 element for this Criterion
12.0 pts
Satisfactory
Missing 2 elements for this Criterion
8.0 pts
Needs Improvement
Missing 3 elements for this Criterion
0.0 pts
Unsatisfactory
Missing 4 or more elements for the criterion Or No Assignment
15.0 pts
This criterion is linked to a Learning OutcomeAssignment Format Possible Points = 10 Points
Format Criterion 1
Grammar, Spelling, Syntax, Mechanics and APA Format
10.0 pts
Excellent
0-1 errors in grammar, syntax, spelling, punctuation, mechanics, or APA format
9.0 pts
V. Good
2-3 errors in grammar, syntax, spelling, punctuation, mechanics, or APA format
8.0 pts
Satisfactory
4-5 errors in grammar, syntax, spelling, punctuation, mechanics, or APA format
5.0 pts
Needs Improvement
6-7 errors in grammar, syntax, spelling, punctuation, mechanics, or APA format
0.0 pts
Unsatisfactory
8 or more errors in grammar, syntax, spelling, punctuation, mechanics, or APA format Or No assignment
10.0 pts
This criterion is linked to a Learning OutcomeLate Penalty Deductions
Students are expected to submit assignments by the time they are due. Assignments submitted after the due date and time will receive a deduction of 10% of the total points possible for that assignment for each day the assignment is late. Assignments will be accepted, with penalty as described, up to a maximum of three days late, after which point a zero will be recorded for the assignment. Quizzes and discussions are not considered assignments and are not part of the late assignment policy.
NR509 Shadow Health SOAP Note Template
0.0 pts
Minus Points NR509 Shadow Health SOAP Note Template
0.0 pts
Minus Points
0.0 pts
Total Points: 75.0
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