Mastering SOAP note writing takes practice, but they’re an essential tool for documenting and communicating patient information. Here are Musculoskeletal SOAP note examples and Lower back pain soap notes samples to guide your nursing studies.
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Musculoskeletal SOAP note examples
CC: lower back pain x 1 week
HPI: 42-year-old obese female presents with complaints of lower back pain for the past week that feels worse today. The pain is constant and intermittently radiates down her left leg. It is not improved with ibuprofen. She works as a grocery store clerk.
Review of systems:
General: No fever, chills, weight changes or sweating, or general weakness.
Eyes: No blurred or double vision or pain or redness.
Ears: No pain or decrease in hearing.
Nose: No runny nose or blockage or bleeding.
Throat: No sore throat.
Head: No headache.
Chest: No chest pain or cough or shortness of breath or wheezing.
Breasts: No pain or tenderness or noticeable lump.
Heart: No irregular heart beat or palpitations or chest pain.
Gastrointestinal: No nausea or vomiting or constipation or difficulty swallowing or rectal bleeding or bloating or distension or hemorrhoids or diarrhea or abdominal discomfort.
Genitourinary: No vaginal discharge or bleeding or dysuria or vaginal problems.
Musculoskeletal: No muscle problems or weakness. Lower back pain that radiates down left leg.
Skin: No rashes or bruises or skin masses or other skin complaints.
Neurologic: No weakness or headache or seizures or numbness or tingling.
Psychiatric: No anxiety or depression or suicidal/homicidal thoughts.
Endocrine: No excessive thirst or excessive urination or excessive heat or cold.
Immunologic: No tuberculosis or hepatitis or HIV or recurrent infections.
Hematologic: No anemia or easy bruising or bleeding.
Musculoskeletal SOAP note examples
PMHx: none
FamilyHx: none
SocialHx: Pt works as a grocery store clerk
Allergies: NKA
Objective:
66 in
275 lb
44.4
122/75 mmHg
78 bpm
14 bpm
97.6 °F
99 %
General: Normotensive, in no acute distress.
Head: Normocephalic, no lesions.
Eyes: PERRLA, EOM’s full, conjunctivae clear, fundi grossly normal.
Ears: EAC’s clear, TM’s normal.
Nose: Mucosa normal, no obstruction.
Throat: Clear, no exudates, no lesions.
Neck: Supple, no masses, no thyromegaly, no bruits.
Chest: Lungs clear, no rales, no rhonchi, no wheezes.
Heart: RR, no murmurs, no rubs, no gallops.
Abdomen: Soft, no tenderness, no masses, BS normal.
Back: Normal curvature, no tenderness.
Extremities: FROM, no deformities, no edema, no erythema.
Neuro: Physiological, no localizing findings.
Skin: Normal, no rashes, no lesions noted.
Assessment: (Musculoskeletal SOAP note examples)
Actual Dx:
- (E66.0) Obesity, body mass index (bmi 40-44.9).
- (M54.5) Dorsalgia, acute low back pain.
ICD-10-CM Codes. (2019). Retrieved from https://www.icd10data.com/ICD10CM/Codes/
Plan (Musculoskeletal SOAP note examples):
– begin medications listed below as needed.
– pt educated on the importance of weight loss and dietary modification to reduce back strain
– RTC for follow-up in 30 days if symptoms persist
- Ultram (tramadol) 100 MG Oral Tablet Sig: Take 1 tablet (100 mg) by mouth every 6 hours as needed for pain. #40, no refills.
- Flexeril (cyclobenzaprine) 10 MG Oral Tablet Sig: Take 1 tablet (10 mg) by mouth every 8 hours as needed. Take at bedtime if drowsiness occurs. #30, no refills.
Ultram, Flexeril: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing. (2019). Retrieved from https://www.webmd.com/drugs
Education:
Provide education to pt on the importance of dietary modification and exercise in order to lose weight and reduce strain on her back. Stress the importance of establishing goals and the health benefits associated with a healthy BMI. If necessary and pt continues to struggle in 30 days will be referred to a dietician for additional support on nutrition and increasing her level of physical activity (UpToDate, 2019).
Mastering SOAP note writing takes practice, but they’re an essential tool for documenting and communicating patient information. Here are Musculoskeletal SOAP note examples and Lower back pain soap notes samples to guide your nursing studies.
Musculoskeletal SOAP note example
History & Physical Examination
Patient Demographics:
Name: T.H.
Age/race/sex: 26 Hispanic Female
Clinical site: Primary Care clinic; Presents for sick visit.
SUBJECTIVE DATA (Musculoskeletal SOAP note examples)
Chief Complaints: “My lower back has been hurting for about 2 weeks now”.
History of Present Illness:
Mrs. H is a 26 y/o Hispanic female with a six-year history of depression-controlled on Sertraline, who presents to the clinic today complaining of spontaneous occurring acute low back pain to the lumber region that started about 2 weeks ago after wearing heels to a party. Reports it has been very difficult to dress lower body and to bend. She reports the pain is constant but has intermittent intensities of aching and soreness throughout the day. The pain is localized to the lumber area, described as aching and soreness with no radiation, rated a 5/10 in office today with 3/10 being the lowest amount of pain experienced and 8/10 being the worst pain she has experienced. Reports the pain is worse in the mornings when getting out of bed after lying down all night. She hasn’t tried any pharmacological or non-pharmacological therapies. She reports no heavy lifting, strenuous exercise, current injuries, nor feelings of anxiety or depression. However, about 5 years ago she was riding her bike, went down a ramp and flipped head first over the handle bars of the bike. At which time she experienced this same low back pain, went to the ER and had X-rays that showed some inflammation and swelling. She was then prescribed a muscle relaxant, Ibuprofen, and physical therapy for 8 weeks, which helped tremendously. At today’s visit, she hopes to find out where the pain is coming from and what she can do to prevent it from returning. Lower back pain soap note examples
Past Medical History:
- Depression-active- diagnosed 6 years ago after mom passed in a MVA
- Low back pain-active-diagnosed about 5 years ago after previous back injury.
Past Surgical History:
- No surgeries to date
Allergies:
NKA to food, dust, mold, environment, or medications.
Medications:
Sertraline 150 mg by mouth daily for depression
Health Maintenance:
- Influenza Vaccine-October 2017 at CVS.
- All other immunizations are up-to-date including TDaP, MMR, and Varicella.
- Last Pap smear- June 2016-normal
- Performs MSBE
- Depression screen positive for PHQ2; on meds and see Psychologists regularly.
- CAGE 0/4
Personal & Social History:
- Lives alone in a one-bedroom apartment.
- Works at a nursing home as a Certified Nursing Assistant 4 days/week. She loves her job and has a dependable car.
- Denies any smoking, illicit drug abuse, or alcohol misuse.
- Previously did cross-fit in high school. However, do to work she hasn’t had much time to get the amount of exercise she needs.
- The patient is sexually active with only one sex partner, her boyfriend.
- 24-hour diet recall: B- one bowl of Chex cereal; L- a turkey sandwich, chips, and a diet coke; S-about 1-2 cups of cheese-it crackers and diet coke; D- Meatloaf, veggies, mashed potatoes from Boston Market, and a bottled water. Lower back pain soap note examples
Family History:
Grandparents
Paternal: Paternal grandfather 81, HTN, DM; Paternal grandmother 76 histories of DM and MI.
Maternal: Maternal grandfather died at 82 from MI, maternal grandmother 79, and history of diabetes and arthritis.
Parents
Father: Father 59, history of HTN, Diabetes, Depression, and Stroke.
Mother: Mother 52, died of an MVA.
Siblings
Siblings: Only child.
Children
Children: No children.
Review of Systems (Musculoskeletal SOAP note examples):
| General | Denies any fever, chills, night sweats, weight loss or weight gain in the past year. |
| Skin | Denies dry skin and itching. Denies abnormal lesions or new nevi/moles |
| Head | Previous head injury, denies any masses, lesions and headache |
| Eyes | Denies any discharge, itchy, blurred vision, vision loss or vision changes, eye pain or injection. |
| Ears | Denies any itching, fullness, vertigo, ear pain or drainage, hearing loss or changes in quality of hearing. |
| Nose/Sinuses | Denies epistaxis, PND, maxillary or frontal sinus pain, or changes in smell |
| Mouth/Throat | Denies sore throat and dysphagia. Denies gum disease, has all original teeth, last dental exam was in July of this year, sees the dentist annually. |
| Neck/Lymph Nodes | Denies swollen /painful lymph nodes, denies any neck pain or stiffness. Lower back pain soap note examples |
| Breasts | Denies masses, pain, or nipple discharge. Does perform regular SBE. |
| Thorax/Respiratory | Denies any SOB, DOE, or wheezing. |
| CVS | Denies CP, palpitations, denies peripheral edema, Orthopnea |
| GI/Abdomen | Denies dyspepsia, nausea, vomiting, diarrhea, constipation, bloating, hematemesis, hematochezia, or abdominal pain. No recent changes in bowel habits. Last bowel movement was this morning, which is consistent with her regular bowel habits and was normal. |
| GU | Denies any pain on urination, frequency, urgency, or vaginal discharge. |
| Musculoskeletal | See HPI. |
| Neurologic | Denies memory loss, numbness, tingling, or burning pains or weakness. |
| Endocrine | Denies known glucose abnormalities, heat or cold intolerance |
| Psychiatric | Reports a history of depression but denies any anxiety. |
OBJECTIVE
Physical Examination:
| Vital Signs/HT/WT | T: 98.2F, P: 72 readily palpable, RR: 16, BP 110/64 on right, 110/68 on the left SaO2 on RA: 100% HT: 5’8”, WT: 128lbs (toned-physique, stable with no gains or losses within the last 6 months), BMI: 19.46, normal for ht. and wt. |
| General | 26 y/o Hispanic female, pleasant appears her stated age sitting on the examination table in moderate distress as evidenced by arms tensed on elbows as she’s guarding pain. Well groomed, well developed, AAOx3 |
| Skin | Warm, moist, no rashes or suspicious moles, +turgor |
| Head/Scalp | ATNC, thick black hair, no dandruff, no lesions/masses. |
| Eyes | External examination without ptosis, strabismus or exophthalmos. Conjunctiva pink. Rest of exam deferred. |
| Ears | Auricles symmetrical, no lesions or tophi; Rest of exam deferred. |
| Nose | Bilateral nasal turbinates’ pink, moist. Rest of exam deferred. |
| Sinuses | Deferred |
| Mouth | Lips pink, moist mucous membrane, tongue protrudes in midline. |
| Pharynx/Throat | Deferred. Lower back pain soap note examples |
| Neck/Lymph nodes | Trachea midline with full AROM without pain. |
| CVS | RRR, normal S1, S2, no murmurs, rubs, or extra systole, JVD 3cm at 30 degrees, no carotid bruits, no cyanosis or vascular lesions. No chest wall deformity. PMI at 5th ICM MCL. Non-tender without heaves or thrill. Auscultation of the abdomen without bruit. Palpation without pulsatile masses |
| Lungs/Thorax | Chest symmetrical without deformity, respirations even and unlabored throughout anterior and posterior lung fields. Palpation without tenderness. Tactile fremitus present. Resonance heard on percussion throughout anterior and posterior lung fields. Vesicular breath sounds auscultated throughout anterior and posterior peripheral lung fields. |
| Breasts | Deferred |
| Abdomen | Deferred |
| GU | Deferred |
| Musculoskeletal | Mandible moves in midline TMJ palpation without clicks or tenderness. Neck and cervical spine have no noted deformities or signs of inflammation. Curvature of cervical, thoracic and lumbar spine within normal limits. Bony features of shoulders and hips are of equal height bilaterally and non-tender. Posture is slumped and gait is smooth but guarded. Palpation of spinous processes of C7-L5 are palpable, midline, and tender to deep palpation right below L5. Discomfort noted with lying flat on exam table. Patient can bend to touch toes but experiences discomfort at about 90 degrees from the upright position. Although patient can actively perform such maneuvers as bending her knees to her chest while lying flat, flex, extend, and rotate the spine there is some mild discomfort and pain noted throughout the maneuvers. |
| Extremities/Pulses | No edema, erythema or cyanosis to upper or lower extremities. Pulses 2/4 to bilateral femoral, popliteal, posterior tibial, and dorsalis pedis pulses. |
| Neurologic | AA O X3. Slumped posture while sitting and walking. Gait steady and intact. Sensation intact to light, deep, and sharp touch. gait and balance intact. CN II- XII intact. Memory and cognition intact for present and past medical history. |
| Psych | Appropriate mood and affect |
Evidence-Based Assessment/Plan
Clinical Decision Making: 26 y/o Hispanic female presents to the primary care clinic with a two-week history of constant low back pain worse when ambulating and dressing. The pain is non-radiating and has intermittent intensities of aching and soreness consistent with acute non-specific low back pain. She has experienced these symptoms before after a biking accident 5 years ago. Given Mrs. H’s presenting signs and symptoms there is a need to differentiate between the diagnosis of acute non-specific low back pain and low back pain with radiculopathy. Mrs. H is an otherwise healthy young female with a history of depression controlled on antidepressants. She has no other co-morbidities or health issues.
Differential Diagnosis:
| CHARACTERISTICS OF DIFFERENTIAL DIAGNOSIS | SIGNS AND SYMPTOMS | PHYSICAL EXAM FINDINGS |
| Non-specific Acute Low Back Pain Nonspecific or nonradicular low back pain is not associated with neurologic symptoms or signs. In general, the pain is localized to the spine or paraspinal regions (or both) and does not radiate into the leg. In general, nonspecific low back pain is not associated with spinal nerve root compression. Nonspecific low back pain might or might not be associated with significant pathology on magnetic resonance imaging (MRI) and is often a result of simple soft tissue disorders such as strain, but it can also be caused by serious medical disorders arising in the bony spine, parameningeal, or retroperitoneal regions. Risk factors: Smoking, obesity, older age, female gender, physically strenuous work, sedentary work, a stressful job, job dissatisfaction, and psychological factors such as anxiety or depression. Diagnosis: Diagnosis is based on physical exam findings. Routine spine radiographs are of limited value because they visualize only bony structures. Guidelines from the U.S. Agency for Health Care Policy and Research (AHCPR) indicated the value of routine spine radiographs for acute low back pain in the following settings: acute major trauma, minor trauma associated with risk of osteoporosis, risk of spinal infection, pain that does not respond to rest or recumbency, and history of cancer, fever, or unexplained weight loss. They may also be of value in assessing spinal alignment and rheumatologic disorders of bone. The American Academy of Neurology guideline recommends nonsurgical therapy before CT and MRI are used in patients with uncomplicated acute low back pain of fewer than 7 weeks duration. | Pain areas: in the low back, muscles and bones, hip, or leg. Sensory: leg numbness or pins and needles. Back joint dysfunction or muscle spasms. Slumped gait due to pain on standing upright. | Some physical exam findings of low back pain may include the following; Superficial tenderness over the lumbar region to light touch Nonanatomic tenderness Exacerbation of pain by applying a few pounds of pressure with the hands to the top of the head Exacerbation of pain by simulated rotation or flexion of the spine Ability to sit up straight from a supine position, but intolerance of the straight-leg-raising test Nonanatomic distribution of sensory changes |
| Acute lumbosacral radiculopathy Low back pain accompanied by spinal nerve root damage is usually associated with neurologic signs or symptoms and is described as radiculopathy. There is usually pathologic evidence of spinal nerve root compression by disk or arthritic spur, but other intraspinal pathologies may be present and are often apparent on an MRI scan of the lumbosacral spine. Risk factors: Traumatic injuryLumbar sprain or train postural strain sitting, standing or walking >2hrs per day frequent moving or lifting >25 lbs. strength <50% depression obesity poor health prior LBP poor back endurance Osteoarthritis Rheumatoid Arthritis Diagnosis: After the initial examination, the diagnosis of lumbar radiculopathy can be supported by electrodiagnosis, MRI, CT scans, and/or contrast myelography. Treatment of lumbar radiculopathy will vary depending on the actual cause of the radiculopathy. These treatments can include the use of back supports, medication, physical therapy, steroid injection in the spine, and even surgery.http://www.aanem.org | Radiculopathy — A common feature of low back pain is radiculopathy, which occurs when a nerve root is irritated by a protruding disc or arthritis of the spine. Radiculopathies usually cause radiating pain, numbness, tingling, or muscle weakness in the specific areas related to the affected nerve root, usually the lower leg. Most people with these conditions improve with limited or no treatment, described below.Lower back pain soap note examplesSciatica — Sciatica refers to the most common symptom of radiculopathy. It is a pain that occurs when one of the five spinal nerve roots, which are branches of the sciatic nerve, is irritated, causing a sharp or burning pain that extends down the back or side of the thigh, usually to the foot or ankle. You may also feel numbness or tingling. Occasionally, the sciatica may also be associated with muscle weakness in the leg or the foot. If a disc is herniated, sciatic pain often increases with coughing, sneezing, or bearing down.Neurogenic claudication — Neurogenic claudication is a type of pain that can occur when the spinal cord is compressed due to narrowing of the spinal canal from arthritis or other causes. The pain runs down the back to the buttocks, thighs, and lower legs, often involving both sides of the body. This may cause limping and weakness in the legs. Pain usually gets worse when extending the lower spine (e.g., when standing or walking), and gets better when flexing the spine by sitting, stooping, or leaning forward. The onset of symptoms in patients with lumbosacral radiculopathy is often sudden and includes LBP. Some patients state the preexisting back pain disappears when the leg pain begins.Sitting, coughing, or sneezing may exacerbate the pain, which travels from the buttock down to the posterior or posterolateral leg to the ankle or foot.Radiculopathy in roots L1-L3 refers pain to the anterior aspect of the thigh and typically does not radiate below the knee, but these levels are affected in only 5% of all disc herniations.When obtaining a patient’s history, be alert for any red flags (i.e., indicators of medical conditions that usually do not resolve on their own without management). Such red flags may imply a more complicated condition that requires further workup (e.g., tumor, infection). The presence of fever, weight loss, or chills requires a thorough evaluation. Patient age is also a factor when looking for other possible causes of the patient’s symptoms. Individuals younger than 20 years and those older than 50 years are at increased risk for more malignant causes of pain (e.g., tumor, infection). |
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POC LABS to Review (Here are Musculoskeletal SOAP note examples and Lower back pain soap notes samples to guide your nursing studies.)
No POC labs to review
Diagnosis 1-Guidelines for Treatment for Non-Specific Acute Low Back Pain (most likely dx): There is general agreement that patients with acute nonspecific spine pain or nonlocalizable lumbosacral radiculopathy (without neurologic signs or significant neurologic symptoms) require only conservative medical management. Patients should abstain from heavy lifting or other activities that aggravate the pain. Bed rest is not helpful and has been shown to delay recovery. Bed rest may be recommended for the first few days for patients with severe pain with movement. Recommended medications include nonsteroidal anti-inflammatory drugs such as ibuprofen or aspirin. If there are complaints of muscle spasm, muscle relaxants such as cyclobenzaprine may be used in the acute phase of pain. Narcotic analgesia should be avoided, in general, but it can be prescribed in cases of severe acute pain. A study by Cherkin and coworkers compared standard physical therapy maneuvers and chiropractic spinal manipulation for the treatment of acute low back pain and found that both provide small short-term benefits and improve patient satisfaction.
Nonpharmacologic treatment, including superficial heat, massage, acupuncture, or spinal manipulation, should be used initially for most patients with acute or sub-acute low back pain, as they will improve over time regardless of treatment. When pharmacologic treatment is desired, nonsteroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants should be used. Avoid imaging in cases of uncomplicated low back pain (unless there are specific clinical indications).
Medications prescribed today;
- Diclofenac Sodium 50 mg 1 by mouth twice daily for pain for 2 weeks.
- Flexeril (Cyclobenzaprine) 10 mg 1 tab by mouth three times a day as needed for muscle spasms for 2 weeks.
Diagnostic test needed:
No further diagnostic test needed at this time. Diagnosis was based on clinical presentation, history, and physical exam.
Referrals/Consults:
Referral for physical therapy to evaluate and treat for low back pain and spasms.
Patient Education:
Remaining active — many people are afraid that they will hurt their backs further or delay recovery by remaining active. However, remaining active is one of the best things you can do for your back. In fact, prolonged bed rest is not recommended. Studies have shown that people with low back pain recover faster when they remain active. Movement helps to relieve muscle spasms and prevents loss of muscle strength.
Although high-impact activities should be avoided, it is fine to continue doing regular day-to-day activities and light exercises, such as walking. If certain activities cause the back to hurt too much, it is fine to stop that activity and try another.
If back pain is severe, bedrest may be necessary for a short period of time, generally no more than one day. When in bed, the most comfortable position may be to lie on the back with a pillow behind the knees and the head and shoulders elevated, or to lie on the side with the upper knee bent and a pillow between the knees.
Heat — using a heating pad can help with low back pain during the first few weeks. It is not clear if cold packs help as well.
Work — most experts recommend that people with low back pain continue to work so long as it is possible to avoid prolonged standing or sitting, heavy lifting, and twisting. Some people need to stay home from work if their occupation does not allow them to sit or stand comfortably. While standing at work, stepping on a block of wood with one foot (and periodically alternating the foot on the block) may be helpful.
Pain medications — Take medications on a regular basis for two weeks for it to be effective, rather than using the medication only when the pain becomes unbearable.
If needed, take muscle relaxant before bedtime. Do not take this medication while driving or operating machinery.
Exercise — a program of exercises can help to increase back flexibility and strengthen the muscles that support the back. Although starting back exercises or stretching immediately after a new episode of low back pain might temporarily increase the pain, the exercise may reduce the total duration of pain and prevent recurrent episodes. Lower back pain soap note examples
Recommended activities include those that involve strengthening and stretching, such as walking, swimming, use of a stationary bicycle, and low-impact aerobics. Avoid activities that involve twisting, bending, are high-impact, or make the back hurt more. Some specific exercises may help strengthen the muscles of the lower back. People with frequent episodes of low back pain should continue these exercises indefinitely to prevent new episodes.
Mattress choice – The benefit of a firm mattress in preventing or treating low back pain has not been proven. In one study, medium-firm mattresses were more likely to improve chronic back pain compared with firm mattresses
Diagnosis 2-Guidelines for Treatment for Acute Lumbosacral Radiculopathy:
The initial treatment of the patient with lumbosacral radiculopathy presenting with sensory symptoms and pain without significant neurologic deficits is not different from the approach for the patient with uncomplicated low back pain. However, such patients require observation for possible worsening of their neurologic status. For patients with acute lumbosacral radiculopathy, the objectives of treatment are to ameliorate pain (symptomatic treatment) and to address the specific underlying process (mechanism-specific treatment) if necessary
Diagnostic test needed:
If signs and symptoms of radiculopathy, sciatica, or neurogenic claudication exists the patient may require one or more of test including Spinal Radiography, CT scan, MRI, contrast myelography, or electrodiagnosis.
Referrals/Consults:
Referral to an orthopedic surgeon or neurosurgeon is recommended under the following circumstances:
- Increasing neurologic problems (measurable weakness)
- Loss of sensation (e.g., numbness) or bladder and bowel symptoms
- Failure to improve after four to six weeks of nonsurgical management, with
- persistent and severe sciatica and evidence of nerve root involvement.
Patient Education:
Most people with radiculopathy improve with conservative treatment such as medication and PT. Surgery is recommended for some people with radiculopathy. They, too, usually improve after a recovery period. Following treatment, most people are able to work and take part in other daily activities. Patient education would include education to prevent acute non-specific low back pain in addition to reducing chances of developing radiculopathy by maintaining good posture and a healthy weight. Using safe techniques when lifting heavy objects to prevent injuries to your back. Remembering to lift with your knees. That means you should bend your knees, not your back. Also asking for help when moving heavy or bulky objects and when doing repetitive tasks, take frequent breaks.
Prevention:
There are a number of ways to prevent low back pain from returning. Perhaps the most important are exercise and staying active. Regular exercise that improves cardiovascular fitness can be combined with specific exercises to strengthen the muscles of the hips and torso. The abdominal muscles are particularly important in supporting the lower back and preventing back pain. It is also important to avoid activities that involve repetitive bending or twisting and high-impact activities that increase stress in the spine.
Bend and lift correctly — People with low back pain should learn the right way to bend and lift. As an example, lifting should always be done with the knees bent and the abdominal muscles tightened to avoid straining the weaker muscles in the lower back (p
Take a break — People who sit or stand for long periods should change positions often and use a chair with appropriate support for the back. An office chair should be readjusted several times throughout the day to avoid sitting in the same position. Taking brief but frequent breaks to walk around will also prevent pain due to prolonged sitting or standing. People who stand in place for long periods can try placing a block of wood on the floor, stepping up and down every few minutes.
Healthcare Maintenance/Recommendations:
Annual Influenza vaccine education provided-Received in October of 2017
Depression screen-positive- Recommended continuing Sertraline and visits to Psychologists as scheduled.
CAGE-0/4
STI and STD education
Sex behavioral counseling
Reinforced recommendations for MSBE
Cervical Cancer screen and HPV education-Recommended continuing routine Pap testing every 3 years.
Diet and exercise education- Recommended to exercise at least 3 days/week; with exercises to help strengthen the core muscles. Continue eating a healthy diet and stay hydrated during workouts.
Recommended using a back brace while at work to help with support with lifting and to call for lifting help instead of trying lift alone.
The USPSTF also recommends high blood pressure, depression, and alcohol misuse screening in this age group. Screening for HIV, Syphilis, HBV, HCV, and STI screening and behavioral counseling is also recommended in all sexually active females in this age group. Although, Mrs. H has a toned physique I think it’s important to counsel her on the importance of daily exercise and physical activity to help reduce pain and on healthful diet practices such as the DASH diet, which is high in grains, fruits, vegetables, and low in fat to help prevent future co-morbidities especially since her family history is so significant for such severe co-morbidities and mortalities.
Follow-up: Follow up in 2 weeks for evaluation of pain management or as needed if pain becomes worse or changes in presentation.
Here are Musculoskeletal SOAP note examples and Lower back pain soap notes samples to guide your nursing studies.
References
American Academy of Family Physicians. (2017). Diagnosis and Treatment of Low Back Pain; Clinical Practice Guidelines. Retrieved from: http://www.aafp.org/patient-care/clinical-recommendations/all/back-pain.html
American Association of Neuromuscular & Electrodiagnostic Medicine. (2017). Lumbar Radiculopathy. Retrieved from: http:www.aanem.org/Patients/Disorders/Lumbar-Radiculopathy
Cleveland Clinic Center for Center for Continuing Education. Published by; Levin, Kerry. M.D. (2010). Low Back Pain. Retrieved from: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/neurology/low-back-pain/#top
Healthline. (2017). Radiculopathy (Pinched Nerve). Retrieved from: https://www.healthline.com/health/radiculopathy#overview1 Lower back pain soap note examples
Scientific Electronic Library Online by Ladeira, Carlos (2011). Evidence based practice guidelines for management of low back pain: physical therapy implications. Retrieved from: http://www.scielo.br/pdf/rbfis/v15n3/04.pdf
U.S. Preventive Services Task Force. (2017). Grade A and B Recommendations. https://www.uspreventiveservicestaskforce.org/Search
UpToDate. (2017). Patient Education. Low Back Pain in Adults (Beyond the Basics). Retrieved from: https://www.uptodate.com/contents/low-back-pain-in-adults-beyond-the-basics Lower back pain soap note examples
Mastering SOAP note writing takes practice, but they’re an essential tool for documenting and communicating patient information. Here are Musculoskeletal SOAP note examples and Lower back pain soap notes samples to guide your nursing studies.
