Our Nursing Papers Samples/Examples

SOAP Note Treatment of COPD


PATIENT INITIALS:  T.Q       AGE: 55            SEX: MALE    RACE: WHITE

CC: difficulty in breathing and restless. 

SUBJECTIVE: Patient is a 97-year-old female patient who was admitted and treated with COPD exacerbation for pneumonia acquired in the community. The patient does have a long COPD history. She doesn't use oxygen at her private, supported home, though. She made changes yesterday, because she was here at the hospital. She needed some oxygen. She was screened and also qualified for home O2 yesterday. They had really strong lungs. She had bilateral wheezes, and more rhonchi on the right. She seemed a little tired and while she was asking to be discharged home, she did not seem to be fit for it.

VITAL SIGNS: The patient’s max temperature over the past 24 hours was 36.5; her blood pressure is 148/77, her pulse is 87 to 106. She is 95% on 2 L via nasal cannula.
HEART: Regular No murmur, gallop or rub.
LUNGS: Reveal no expiratory wheezing throughout. 

ABDOMEN: Soft and nontender. Her bowel sounds x4 are normative.
NEUROLOGIC: She is alert and oriented x3. Her pupils are equal and reactive. She has got a good head and facial muscle strength. Her tongue is midline. She has got clear speech. Her Extraocular motions are intact. Her spine is nontender from neck to lumbar spine on palpation. As with her knees, elbows, wrists and toes, she has a wide range of motion. Her capabilities in the grip are equal in bilateral terms. From extension to flexion both elbows are heavy. Its hip flexors and extenders are both strong and bilateral compatible. Bilateral knee extension and flexion, and ankles are also powerful. Her right knee palpation doesn't show a crepitus. She has suprapatellar inflammation with some bruising and swelling. However, she has a fine joint range of motions.
SKIN: She did have a skin tear involving her right forearm lateral, 

Acute on chronic COPD exacerbation, generalized weakness and deconditioning secondary to the above. Also sustained a fall secondary to instability and not using her walker or calling for assistance. 

Obtain an orthopaedic consult secondary to her fall to evaluate her x-rays and function.



PATIENT INITIALS:  Mrs. P.       AGE: 55            SEX: FEMALE    RACE: WHITE

CC:  The patient came to the hospital for consultation regarding her hypothyroidism.

HISTORY OF PRESENT ILLNESS: This is a 55-year-old female with a history of I-131-induced hypothyroidism years ago who presents with increased weight and edema over the last few weeks with a 25-pound weight gain. She also has a diagnosis of fibromyalgia, inflammatory bowel disease, Crohn’s disease, COPD, and thyroid disorder as well as disc disease.  She's found increased abdominal girth and increased edema in her legs.  She has been in hypertension for years on Norvasc and lisinopril. She has intermittent sweats that have no noticeable improvement in her bowel condition.  She takes away her Synthroid hormone from her.  She's been on generic for the last couple of months and in the past has had problems with that. 

MEDICATIONS: Levothyroxine 300 mcg daily, albuterol, Asacol, and Prilosec. Her amlodipine and lisinopril are on hold.
PAST MEDICAL HISTORY: Inflammatory bowel disease with Crohn, hypertension, fibromyalgia, COPD
PAST SURGICAL HISTORY: Hysterectomy and a cholecystectomy.
SOCIAL HISTORY:  No smoking or drinking
FAMILY HISTORY: Positive for thyroid disease
REVIEW OF SYSTEMS: Positive for fatigue, sweats, and weight gain of 20 pounds. PHYSICAL EXAMINATION:
GENERAL: She is an obese female.
VITAL SIGNS: Blood pressure 140/70 and heart rate 84. She is afebrile.
HEENT: Extraocular movements were intact. There was moist oral mucosa.
NECK: Supple. Thyroid gland atrophic and nontender.
CHEST: good

ABDOMEN: Benign.
EXTREMITIES: Showed 1+ edema.
NEUROLOGIC: She was awake and alert.
LABORATORY DATA: TSH 0.28, free T4 1.34, total T4 12.4 and glucose 105.
IMPRESSION/PLAN: This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism.  Hypothyroidism with the disorder Graves several years earlier is similar to radioactive iodine. 

She is a euthyroid clinically and biochemically. 

Her TSH is slightly suppressed, but her free T4 is fine, 

and I will not decrease her levothyroxine dose with her weight gain. 

I'm going to stay 

On Synthroid 300 mcg daily. 

If she wants to lose more weight, in six weeks ' time I 

Would perform the thyroid function test to ensure she also isn't hyperactive thyroid. 



Soap Note Example For Anemia

PATIENT INITIALS:  T.Q       AGE: 55            SEX: MALE    RACE: WHITE

CC:  Patient came in with iron deficiency anemia and had blood in his stool.

HISTORY OF PRESENT ILLNESS: Patient is a 55-year-old gentleman. He developed deficiency anemia and he had blood in his stool. Anemia was diagnosed months ago when he presented with unusual pruritus and he got a CBC. At that time he was discovered to have haemoglobin of 9 and MCV 65.
PAST MEDICAL HISTORY: Chronic diarrhoea, Chronic obstructive pulmonary disease.
MEDICATIONS: Iron supplement.
FAMILY HISTORY: Coronary artery disease, hypertension.  Non history of colon cancer or any type of other cancer.
SOCIAL HISTORY: Patient smokes 1-1/2 packs for more than 40 years. 6 beers per day and no drug history.
REVIEW OF SYSTEMS: No night sweats. Good appetite. Stable weight. No chills, no fevers. No visual problems. No hearing problems. Chronic diarrhoea for more than 3 years. His stool is daily, 1-2 times per day and very loose with dark and bright blood in the stool on and off for more than 5 months. Respiratory review of systems was significant for COPD. Patient not on oxygen and his COPD is mild. Denies any neurological problems, psychiatric problems, endocrine problems, haematological problems, lymphatic problems, immunological problems, allergy problems.

VITAL SIGNS: Weight 221 pounds. Height 6 feet 1 inch. Blood pressure 124/62, heart rate 87, and temperature 98.4, saturation 98%. Pain is 0/10.
GENERAL: Good attention to grooming.
HEENT: PERRLA. EOM intact. Oropharynx is clear of lesions. Good dentition.
NECK: Supple.
LUNGS: Clear to auscultation No wheezing and crackles. 

CARDIOVASCULAR: Regular rate and rhythm...
ABDOMEN: No masses, no tenderness. No distention. 

RECTAL: Good sphincter tone. No palpable nodules. No masses. No blood. Dark stool, the patient is taking iron.
BACK: No costovertebral tenderness bilaterally.
MUSCULOSKELETAL: Good, stable gait. No clubbing, no cyanosis, no pitting edema. Full range of motion. No joint deformities.
SKIN: Clear of rashes and lesions.
NEUROLOGICAL: Cranial nerves II-XII within normal limits. Deep tendon reflexes 2+ in both knees and both biceps. No local weakness.
PSYCHIATRIC: Good judgment and insight.
ASSESSMENT & PLAN: Patient needs evaluation for source of bleeding with a colonoscopy. The patient will need antibiotic prophylaxis prior to procedure because of valvular abnormality and we are not completely aware of what type of abnormality. PSA was in the normal range. The patient had x-ray which showed pulmonary hyperinflation and emphysema. The patient will be followed up with result of colonoscopy.


PRAC 6531_ AGPCNP Clinical Skills and Procedures

Self-Assessment Form


(Can complete independently)

Mostly confident
(Can complete with supervision)

(Have performed with supervision or need supervision to feel confident)

(Have never performed or does not apply)

Biopsy (excision or punch)


Never Performed

Cerumen removal


Clinical breast examination


Digital rectal exam


Never Performed

EKG 12 lead placement and interpretation


Epistaxis management/nasal packing


Fluorescein stain of the eye


Never Performed

Gait and balance assessment


Never Performed

Herpes culture


Never Performed

I &D abscess


Never Performed

CXR interpretation


KOH skin slide for fungus


Never Performed

Laboratory/diagnostic testing-order and/or interpret


Mini Mental Status Exam


Never Performed

Nail examination and removal/nail trephination/subungual hematoma


Never Performed

Nasal packing, removal of


Never Performed

Pap smear


Peak flow meter


Never Performed

Prostate examination


Never Performed

Remove foreign body
(ear, eye, nose, soft tissue, other)


Never Performed

Skin tag removal,

tick removal


Never Performed



Never Performed

PFT interpretation




Wart destruction/removal


Wound care


Radiology reports: Interpret chest X-ray, constipation


Inject local anesthetics


Never Performed

Summary of strengths:


Among the strengths that I realize have when it comes to clinical skills and procedures are as follows: 

  • I have the ability to elaborate the patient’s reasons and concerns for visit, which makes me have the ability to address the mentioned concerns. 

  •  I also realize that I can be able to obtain information from the patient and document the list of assessment based on the assessment checklist, this will provided me with the direction towards patient medication, nutrition and holistic care. 

  • I can collect and document and use the right patient history, in addition to the relevant family and social history of the patient (Jacob et al., 2015). 

  • I am good in decision making especially when it comes to patient compliance with treatment, therapy and medication.  I ensure that they have followed the care instructions, and medication regimen, including making the right lifestyle suggestions

  • I also exhibit empathy when dealing with a patient, this has helped me when I encounter with patients that experience a number of psychological and physical issues. 

  • Also I possess strong communication skills

  • I am a very reliable and flexible person, which means I can adapt to different clinical environment. 


Opportunities for growth:

Among the areas that I felt I require a lot of opportunities for growth include: 

  • Continued education is very important as this will make me become a more specialized nurse practitioner. 

  • On the Job training is also very important as this will ensure that as a nurse practitioner, I am updated with the current practice and current trends in the nursing profession. 

  • I would also like to be responsible as a Family nursing practitioner, where I will take on continued care jobs will patients who have been discharged from the hospital ("Nursing education: Review of assessment, clinical care, and implications for practice regarding older adult patients with cancer," 2018) .  In most cases I would like to deal with chronic condition patients and help them cope and know how to live with and manage the condition. 

  • I also need to educate myself more about patient record keeping, as this is very important in patient care (Misto, 2017).  If it is important to add information into the current record, I need to learn more about labeling or coding since additional information if done the wrong way can alter the patient progress. 


Now, write 3–4 possible goals and objectives for this practicum experience. Ensure that they follow the SMART Strategy, as described in the Learning Resources. 


Goal 1: Learn to apply standard procedures of a hospital

Objective 1:  Find out about the practice requirements of the hospital, including my state Nurse Practice Act so I can be compliant with the professional board and organization’s standard of care. 

Goal 2:  Learn how to conduct documentation of Patient Details

Objective 2:  To find out the impact of using a standard form in patient documentation, and how this assists in clinical decision making,  patient diagnosis, establishing the patient treatment plan and further actions for care and support. 

Goal 3:  Ensure proper documentation and preservation of patient records.

Objective 3:  Find out the impact or patient recording keeping, in development of the patient condition whether admitted or not. 


Jacob, A., Tarachand, J., & R, R. (2015). Health assessment. Clinical Nursing Procedures: The Art of Nursing Practice, 1-1. https://doi.org/10.5005/jp/books/12418_2

Misto, K. (2017). Family perceptions of family nursing in a magnet institution during acute hospitalizations of older adult patients. Clinical Nursing Research, 28(5), 548-566. https://doi.org/10.1177/1054773817748400

Nursing education: Review of assessment, clinical care, and implications for practice regarding older adult patients with cancer. (2018). Clinical Journal of Oncology Nursing. https://doi.org/10.1188/18.cjon.s2.19-25


6551 Week 3 SOAP Note

Genital Assessment


As a nursing practitioner, one is bound to be faced with different number of cases that will call for more examination and evidence based practice.  The following analysis is based on the evaluation of the patient genitalia and the influence it carries on the clinical conclusion regard a patient with complicated data.  This analysis report will thus look at the patient objective and subjective information that is introduced in the SOAP note and come up with additional information which will be incorporated in the medical report.  There will also be use of various evidence based literature that provides analytical tests support in the assessments. There will also be analysis of the patient subjective information that will be documented. As a nursing practitioner, analysis should be done with clinical support on the importance of making a particular diagnosis.  The paper will also provide three conclusions regarding the patient diagnosis.

Subjective Data Analysis

This section provides an analysis of the patient subjective information for regarding the current situation.  Based on the subjective data the patient’s chief complaint was having bumps on my bottom that I need to have looked at”. According to the history of Present Illness, the patient is a 21 year old female undergraduate student that comes to the clinical reporting as having outer bumps in her genital area (Denniston, 2014).  According to the patient, the bumps are not painful however they are rough. Also, from the assessment the patient reports that she is sexually active with multiple partners in the previous year.  The first sexual contact happened when the patient was 18 years. Also, the patient does not have any form of vaginal discharge.  Her major concern is the extent to which the bumps have been there, when she only saw them seven days ago.  The patient also reports that she had her last pap smear three years ago where it turned out negative for dysplasia. The patient also reported that she was once diagnosed with Chlamydia two years ago, she however finished the prescription. The patient also reports having asthma. The medications she has been prescribed for the condition was Symbicort 160.4.5 mg, she has no know allergies (Crouch et al., 2010).  According to family history, the patient denies history of cervical or breast cancer from family members.  The father however has history of GERD and HTN. Based on her social history, the patient does not smoke nor use any form of illicit drug.  Occasionally the patent uses alcohol when she is with friends.

It was very important to understand the subjective information of the patient as this helps in creating a clinical portfolio. Also, the information regarding the patient medical history and family history helps in deciding on a proper conclusion.  It was also important to find out whether she was keeping up with all her vaccination, whether she had been screened for Pap smear and the results as these are some factors that could lead to Human papilloma virus infections if not checked (Liesegang, 2017).  Also, by coming to understand the one she has been seeing as a healthcare provided especially for gynecological visits would be very helpful to assemble.  The patient also reported being sexually active; this means that it would also be important to find out from her who among her sexual partners was positive for STDs and whether she was tested for one.   Based on the date, the patient informed that she was diagnosed with Chlamydia, however, she did not have any other form of STDs. The reason it was important to ask the patient regarding her sexual activity was that it would mean she would have to call for her partners to come and be tested as well. Question about her immunization history was very important since people that do not follow through to immunization often become very vulnerable to infections, and could be at risk of antibodies that are used in the prevention of STDs.

Objective data Analysis

It was also important to assess the patient objective data from the visit.  Based on the objective data her vital signs were not so bad where her temperature stood at 98.6, Blood pressure at 120/86, RR 16, HT 5’10’’ and WT 169lbs.  Her heart was RRR with no murmurs, the lungs CT with an asymmetrical chest wall.  Also while analyzing her genitals, there was a normal female hair pattern distribution, there was no swelling or masses.  The patient’s urethral meatus was intact there was no discharge or erythema. The perineum was intact except for a healed episiotomy scar.  The vaginal mucosa was moist and milk with presence of rugae.  Checking on her abdomen it produced normal active bowel sounds, it was soft, negative Murphy’s and Mc Burney. It was also important to obtain the HSV specimen.  From this analysis there was some examination missing from the objective date. Much concentration was given to the genital evaluation. Other important aspects like the mental and neurological aspects were missing. It is possible that the patient could also be suffering from anxiety due to the bumps in her bottom that might deny her a normal psychological status.  Also, it would be important to look at the head to toe and skin evaluation, including looking at the mucosa in her mouth. Due to her sexual history, it would be in line to conduct full evaluation of the skin (Douglas, 2007).  Also assessing the body in general would help in analyzing the social and biological risks.  Lastly it would also be important to conduct a pregnancy test on the patient to reduce the risk of infection to the baby in case she was pregnant.

Supporting and Rejecting the Assessment

Based on the information gathered from the assessments, it is possible that the patient could be having a chancre, due to the area of the ulcers in the patient genitalia, and the fact that the patient reported the chancre was not painful. One of the reasons I would not support the diagnosis is because there was some absent information leading to some insignificance.  There was also no outcome from demonstrative or HSV testing for infections, which calls for the need to affirm whether the patient has chancre.

Diagnostic tests

Based on the Patient’s Objective information, it is important to conduct HSV testing, especially to understand the presence of sores, it also has a great level of sensitivity. Based on the assessment, the most extreme level of vesicles can be exposed and the base of the patient ulcer can also be traced using a Dacron swab, this will provide the diagnosis with clear information (Liesegang, 2017).  These tests can be repeated after 6-12 weeks. Based on the vital signs, it is evident the patient is not suffering from any sort of fever, however it will be important to conduct a CBC to check on contamination.

Differential Diagnoses

Based on the patient information the following are different diagnoses:


From the analysis of the SOAP it is this is the closest diagnoses because the patient was having bumps in her outer labia.  Also, chancre are usually popular with female patients that report being sexual active with different partners.  Also based on the fact that the patient reported suffering from an STD, previously, could indicate the presence of Chancre which is an indication of the initial phase of syphilis, though the wounds could be varied as those present in her labia (Van Rooijen et al., 2016). Chancres usually appear, round, firm and painless, which is exactly what the patient reported in her subjective data. In most cases chancres will last to about 6 weeks and health with treatment.  However, it can develop to STDs, especially syphilis.


The patient could also have a possible chancroid, however this diagnosis usually present itself as a solitary profound ulcer that is mostly painful. If this was the case, it would also mean that the patient would have a burning sensation which is not reported in a subjective data.  According to the patient, the bumps she has are painless, and she discovered having it for about 7 days. This means that the condition cannot be chancroid.

Herpes Simplex Virus

This could also qualify as a diagnosis for the patient however, based on the subjective and objective data, it is evident that the patient does not report a burning with sores, tingling and basic manifestations common with people suffering from Herpes Simplex Virus (Liesegang, 2017).  As common with any patient suffering from Herpes Labialis, they would depict a burning and tingling sensation, due to the development of a vesicular ulcerative injury which is in the perioral mucosa and oropharynx. However, from the subjective data the patient does not have vesicular sores in her mucosa and oropharynx, there is also no burning sensation or tingling.


The following reported provided a diagnostic analysis of a 21-year-old patient who came to the clinic reporting having bumps on her bottom. Based on the analysis 3 different diagnosis were possible for her condition, however, the closest diagnosis was Chancre based on the subjective and objective data.  


Crouch, N., Michala, L., Creighton, S., & Conway, G. (2010). Androgen-dependent measurements of female genitalia in women with complete androgen insensitivity syndrome. BJOG: An International Journal of Obstetrics & Gynaecology, 118(1), 84–87. https://doi.org/10.1111/j.1471-0528.2010.02778.x

Denniston, G. C. (2014). Genital autonomy: (2010th ed.). Springer.

Douglas, J. M. (2007). Making progress against stds. Skin & Allergy News, 38(2), 12. https://doi.org/10.1016/s0037-6337(07)70017-7

Inamadar, A. C. (2003). Perforating chancre: Any cause-effect relation with HIV infection? Sexually Transmitted Infections, 79(3), 262-262. https://doi.org/10.1136/sti.79.3.262

Liesegang, T. J. (2017). Herpes simplex virus ocular disease. Herpes Simplex Viruses, 239-274. https://doi.org/10.1201/9780203711828-10

Van Rooijen, M. S., Koekenbier, R. H., Hendriks, A., De Vries, H. J., Van Leeuwen, P., & Van Veen, M. G. (2016). Young low-risk heterosexual clients prefer a chlamydia home collection test to a sexually transmitted infection clinic visit in Amsterdam, The Netherlands, a cross-sectional study. Sexually Transmitted Diseases, 43(11), 710-716. https://doi.org/10.1097/olq.0000000000000517