Develop a hospital follow-up progress SOAP note

Academic clinical SOAP notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating evidence-based plans of care.
Develop a hospital follow-up progress SOAP note based on a clinical patient from your clinical/practicum setting. In your assessment, provide the following:
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and the context or service in which the patient is being seen.
A one- or two-paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures. Include how many days the patient has been hospitalized, if applicable.
List of at least five systems affected by the working diagnosis. Provide two positive or negative effects that the working diagnosis has on each system.
List of at least five systems examined within the past 24 hours. Provide at least two pertinent positive or negative findings relevant to each system examined and include a full set of vital signs.
List of all admission diagnostics conducted for this visit or conducted within the past 24 hours.
List of all pertinent acute and chronic diagnoses in order of priority using ICD-10. Identify any differential diagnoses being eliminated.
Treatment plan that corresponds with the diagnosis. Provide information on admission type, types of diagnostics, any prescribed medications and dosages, and any relevant consults or follow-up procedures needed.
Discussion of any relevant ethical, legal, or geriatric-specific considerations.
Incorporate at least three peer-reviewed articles in the assessment or plan.
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion
Benchmark Information
This benchmark assignment assesses the following programmatic competencies:
MSN AGACNP
6.2: Perform focused and comprehensive health assessments.
7.4: Engage patients and families as active participants in culturally relevant, patient-centered care through appropriate education, consultation, and support.
7.5: Deliver clinical prevention interventions and provide restorative care to promote health and prevent disease in the adult-gerontological population.
THE ANSWER
Subjective
Patient is a 75-year-old female with a history of hypertension, diabetes, and hyperlipidemia. She is admitted to the hospital with a diagnosis of pneumonia.
She reports shortness of breath, cough, and fever.
She has been taking her medications as prescribed, but her symptoms have not improved.
She is also complaining of fatigue and weakness.
Objective
Vital signs: Temperature 101.5°F, heart rate 100 beats per minute, respiratory rate 22 breaths per minute, blood pressure 140/90 mmHg
Physical examination: Lungs clear to auscultation bilaterally. No wheezes or rales.
Laboratory tests: White blood cell count 12,000/µL, chest X-ray shows infiltrates in the right lower lobe
Assessment
Primary working diagnosis: Pneumonia
Pending differential diagnoses: Heart failure, chronic obstructive pulmonary disease (COPD), lung cancer
Context or service: Hospitalized in the medical ward
Plan
Continue current medications.
Start antibiotics.
Monitor vital signs and respiratory status.
Get a CT scan of the chest to rule out other diagnoses.
Ethical, legal, or geriatric-specific considerations
The patient is elderly and may have difficulty understanding her condition. It is important to provide her with clear and concise information about her diagnosis and treatment plan.
The patient may also have difficulty managing her medications. It is important to work with her to develop a plan that she can follow.
The patient may also have financial constraints that could affect her care. It is important to be aware of these constraints and to work with the patient to find ways to minimize the cost of her care.
References
“Pneumonia.” Centers for Disease Control and Prevention, 2023, www.cdc.gov/ pneumonia/index.htm.
“Pneumonia in Adults.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 2023, www.mayoclinic.org/diseases-conditions/ pneumonia/symptoms-causes/syc-20354256.
“Pneumonia in Older Adults.” National Institute on Aging, U.S. Department of Health and Human Services, 2023, www.nia.nih.gov/health/topics/ pneumonia/pages/default.aspx.
I hope this helps!