APRN SOAP Note Discussion Paper

ACTIVITY DESCRIPTION
Jacob is a 72-year-old male hospitalized six months ago with new onset diabetes type 2 while experiencing diabetic ketoacidosis. His blood glucose was 543 on admission and he was started on insulin therapy. He saw the Endocrinologist three months ago, and his HgbA1C was 8.8. Medications were adjusted at that time and diabetes education was initiated. A few weeks ago, he returned to the endocrinologist and still had elevated blood glucose readings, despite being adamant that he is strictly following the prescribed diet. Today, Jacob has a telehealth visit with the diabetes education clinic. APRN SOAP Note Discussion Paper

Can you figure out what is going on with Jacob?

After reviewing the EHR chart:

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How would you explain the problem to Jacob during his next visit?
What other healthcare disciplines and community organizations would you involve in the patient’s plan of care, and why?
Document your findings and plan of care in an Adult APRN note:
Subjective APRN SOAP Note Discussion Paper
Chief Complaint (Patient’s own words):
History of Present Illness (If applicable):
Past Medical History
Childhood Illnesses:
Adult Illnesses (Acute/Chronic/Recent):
Surgery/Hospitalizations:
Immunizations:
Accidents/Trauma:
Psychiatric:
OB/Gyn/Reproductive: APRN SOAP Note Discussion Paper
Meds:
Allergies:
Family History:
Psychosocial (HEEADSSSS)
Home Environment:
Education/Employment:
Eating/Exercise:
Activities/Friends:
Drugs/Smoking/Alcohol: APRN SOAP Note Discussion Paper
Sexuality:
Suicide/Depression:
Safety:
Spirituality:
Lifestyle risk assessment:
Health Maintenance:
Review of (Pertinent) Systems:
Objective
Vital Signs Reviewed (Required):
Physical Exam (Pertinent systems only for HPI):
Assessment (Each assessment must be associated with a plan)
Assessment:
Plan (Diagnostic tests, Meds, Pt Ed, Referral/Follow-up)
Plan: APRN SOAP Note Discussion Paper