Posted: January 22nd, 2024

15-year-old female presents with a 2-day history of burning pain

SOAP Note Template

Encounter date: ________________________

Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

Reason for Seeking Health Care: ______________________________________________

HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________

Current perception of Health: Excellent Good Fair Poor
Past Medical History
• Major/Chronic Illnesses____________________________________________________
• Trauma/Injury ___________________________________________________________
• Hospitalizations __________________________________________________________

Past Surgical History___________________________________________________________
Medications: __________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Family History: ____________________________________________________________

Social history:
Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________ Employment Status: ______ Current/Previous occupation type: _________________
Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________
Sexual orientation: _______ Sexual Activity: ____ Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone: _____________________________
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____
Exposures:
Immunization HX:

Review of Systems:
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:

Physical Exam

BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.

Plan:
Differential Diagnoses
1.
2.
3.
Principal Diagnoses
1.
2.
Plan
Diagnosis
Diagnostic Testing:
Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:

Diagnosis
Diagnostic Testing:
Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:

Signature (with appropriate credentials): __________________________________________

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________

DEA#: 101010101 Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________ Refill: _________________
No Substitution
Signature: ____________________________________________________________

Soap note topic: Pediatric Adolescent female with a chief complaint of burning with urination.

SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.

For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:

S = Subjective data: Patient’s Chief Complaint (CC).
O = Objective data: Including client behavior, physical assessment, vital signs, and meds.
A = Assessment: Diagnosis of the patient’s condition. Get custom essay samples and course-specific study resources via course hero homework for you service – Include differential diagnosis.
P = Plan: Treatment, diagnostic testing, and follow up
Submission Instructions:

Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.
Soap note must include prescription at the end for the pediatric patient.
Soap note must be very detailed for the pediatric patient.
Use Soap note template attached below

_______________________
S: Subjective
15-year-old female presents with a 2-day history of burning pain with urination. No other symptoms reported. Denies any recent sexual activity or changes in hygiene.
O: Objective
Vitals: T 37.0°C, P 80, R 18, BP 110/70
General appearance: Well-developed, well-nourished female in no acute distress
HEENT: Normal
Heart: Regular rate and rhythm without murmurs
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, no organomegaly
Extremities: No edema, joints normal ROM
Genitourinary exam: External genitalia normal in appearance without lesions, mild suprapubic tenderness
A: Assessment
Cystitis (most likely diagnosis given symptoms of dysuria without other complaints or risk factors for STI)
UTI
Vulvovaginitis
P: Plan
Order urinalysis to check for signs of infection
Prescribe a 7-day course of nitrofurantoin 100 mg PO BID for presumed cystitis
Recommend drinking plenty of water and avoiding irritants
Follow-up in 1 week if no improvement or worsening of symptoms
Provide education on proper hygiene, voiding habits, and signs of complication
Prescription:
Nitrofurantoin 100 mg capsules
Sig: Take 1 capsule by mouth twice daily for 7 days
Dispense: 14 capsules
Refills: 0

Subjective-objective-assessment-plan (SOAP) notes are a common documentation format used in healthcare settings to record patient encounters. The SOAP note structure provides a systematic way for healthcare providers to assess and address a patient’s condition by recording relevant subjective and objective data, developing a diagnosis or problem list, and outlining a treatment plan. This article will discuss the use of SOAP notes specifically for pediatric patients presenting with urinary symptoms such as burning with urination.
Subjective Data
The subjective, or “S”, section of the SOAP note focuses on collecting the patient’s chief complaint and history of present illness from their perspective. For pediatric patients, it is important to obtain this information directly from the child when developmentally appropriate, as well as from the parent or guardian (Roberts & Wright, 2016: 2024 – Do my homework – Help write my assignment online). Relevant details to include in the subjective section for a pediatric patient with urinary symptoms may include:
Onset, duration, location, and severity of symptoms like burning, pain, or urgency with urination
Associated symptoms like frequency, hematuria, dysuria
Possible precipitating or relieving factors
Prior treatment attempts and response
Menstrual history for female adolescents
Developmental and medical history
Medications, allergies, immunizations (Roberts & Wright, 2016: 2024 – Do my homework – Help write my assignment online)
Objective Data
The objective, or “O”, section involves recording observable, measurable exam findings rather than subjective symptoms. When evaluating a pediatric patient with urinary complaints, the healthcare provider should perform a thorough physical exam and note findings such as (Roberts & Wright, 2016: 2024 – Do my homework – Help write my assignment online):
Vital signs including temperature, blood pressure, pulse, and respiratory rate
General appearance and development
HEENT, heart, lung, abdominal, skin, extremity, and neurological exams
For females, a genitourinary exam noting appearance of external genitalia and presence of lesions, discharge, tenderness, etc.
It is also important to document the results of any diagnostic testing in the objective section. For a urinary complaint, this may include a urinalysis assessing for signs of infection like white and red blood cells, nitrites, leukocyte esterase (Roberts & Wright, 2016: 2024 – Do my homework – Help write my assignment online).
Assessment
In the assessment, or “A”, section, the provider analyzes the subjective and objective data to formulate a diagnosis or problem list with differential diagnoses. For a pediatric patient presenting with burning urination, common diagnoses to consider include (Roberts & Wright, 2016: 2024 – Do my homework – Help write my assignment online):
Urinary tract infection (UTI)
Cystitis (bladder infection)
Urethritis
Vulvovaginitis
Sexually transmitted infection like chlamydia or gonorrhea (for sexually active adolescents)
Interstitial cystitis
Physical or sexual abuse
The provider should list their primary diagnosis first followed by important differential diagnoses to rule out.
Plan
Lastly, the plan, or “P”, section outlines the treatment, follow-up, and anticipatory guidance based on the established diagnosis. Elements of the plan for a pediatric urinary complaint may include (Roberts & Wright, 2016: 2024 – Do my homework – Help write my assignment online):
Prescription of antibiotics if infection is diagnosed, with dosage and duration
Recommendations for fluid intake, hygiene, voiding habits
Follow-up appointment time frame or instructions for worsening symptoms
Referrals to urology or other specialists as needed
Patient education on diagnosis, treatment plan, prevention
Anticipatory guidance regarding development, sexuality, risk reduction
Proper documentation of the treatment plan is important for continuity of care. Prescriptions should also be included in the note with all required elements.
Conclusion
In summary, the SOAP note format provides a systematic approach for healthcare providers to assess, diagnose, and manage pediatric patients presenting with urinary symptoms. Thorough collection and documentation of subjective and objective data helps formulate an accurate diagnosis and appropriate treatment plan. Proper use of the SOAP note structure can aid clinical decision making and communication between providers.
References:
Roberts, M. W., & Wright, P. W. (2016: 2024 – Do my homework – Help write my assignment online). Common pediatric conditions: Office evaluation and management. American family physician, 94(1), 37-45.
Suliman, S., Welkom, J. S., & Fenstermacher, K. (2016: 2024 – Do my homework – Help write my assignment online). Comparison of documentation methods for the inpatient medical record. Applied clinical informatics, 7(2), 479.
Wright, S. W., & Zborowsky, T. (2017). SOAP notes: write it, don’t type it. Journal of medical practice management: MPM, 32(6), 349-351.

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