NRNP 6665 SOAPNOTE SAMPLE
NRNP 6665 SOAPNOTE SAMPLE
Psychosocial Disorders in the Older Population
Nancy S. Doctura
Walden University
NRNP 6540F Advanced Practice Care of Older Adults
Dr. Donna Petko
Psychosocial Disorders in the Older Population
As a person ages, many physiologic changes occur. Normal degenerative changes happen
that affect many brain functions. As advanced practice registered nurses, it is crucial that they
perform a comprehensive assessment on their elderly patients to be able to create a treatment
plan that will manage their medical conditions effectively. In this paper, the goal is to present a
detailed subjective, objective, assessment, and plan (SOAP) for an older adult with psychosocial
disorders. The paper also aims to reflect learning points from analyzing the psychosocial
disorders, their respective diagnostic studies, and treatment plans. Functional and behavioral
changes in geriatric patients should alert the providers to carefully evaluate potential medical
conditions and create a plan that will preserve or maintain their health and physical well-being.
Comprehensive SOAP
Patient Information:
,NRNP 6665 SOAPNOTE SAMPLE
Mrs. P, 70, F, White, Female
Chief Complaint: Mrs. Peters was brought to the clinic by her son complaining of acute
confusion (more than usual) and some agitation and restlessness.
History of Present Illness:
Mrs. Peters is a 70-year-old white female who comes to the clinic accompanied by her
son, Jared, with reports of acute confusion that was worse than baseline, agitation and
restlessness. The symptoms were noted two days ago by her son. Yesterday, Ms. P could not
remember where she was in her own room. She was seen three days ago by her primary doctor
, NRNP 6665 SOAPNOTE SAMPLE
where her blood pressure was noted to be elevated; hence, her prescription for her blood pressure
medication, Hydrochlorothiazide, was increased to 50 mg daily. No contributing trauma nor fall
were reported by son. No changes in diet or routine regimens were reported.
Current Medications:
Multivitamin daily
Losartan 50 mg daily
Hydrochlorothiazide 50 mg daily
Fish Oil 1 tablet daily
Glyburide 5 mg daily
Metformin 500 mg twice a day
Donepezil 10 mg daily
Alendronate 70 mg orally once a week
Allergies: Atorvastatin
Past Medical History:
Dementia, Hypertension, Diabetes, Osteoporosis, Chronic Allergic Rhinitis
Immunization status unknown
Last seen by primary physician 3 days ago
Social and Substance History:
Lives at home with son. Unknown tobacco, alcohol, and drug use.
Family History:
Family history unknown
Surgical History:
No surgical history was reported
NRNP 6665 SOAPNOTE SAMPLE
Psychosocial Disorders in the Older Population
Nancy S. Doctura
Walden University
NRNP 6540F Advanced Practice Care of Older Adults
Dr. Donna Petko
Psychosocial Disorders in the Older Population
As a person ages, many physiologic changes occur. Normal degenerative changes happen
that affect many brain functions. As advanced practice registered nurses, it is crucial that they
perform a comprehensive assessment on their elderly patients to be able to create a treatment
plan that will manage their medical conditions effectively. In this paper, the goal is to present a
detailed subjective, objective, assessment, and plan (SOAP) for an older adult with psychosocial
disorders. The paper also aims to reflect learning points from analyzing the psychosocial
disorders, their respective diagnostic studies, and treatment plans. Functional and behavioral
changes in geriatric patients should alert the providers to carefully evaluate potential medical
conditions and create a plan that will preserve or maintain their health and physical well-being.
Comprehensive SOAP
Patient Information:
,NRNP 6665 SOAPNOTE SAMPLE
Mrs. P, 70, F, White, Female
Chief Complaint: Mrs. Peters was brought to the clinic by her son complaining of acute
confusion (more than usual) and some agitation and restlessness.
History of Present Illness:
Mrs. Peters is a 70-year-old white female who comes to the clinic accompanied by her
son, Jared, with reports of acute confusion that was worse than baseline, agitation and
restlessness. The symptoms were noted two days ago by her son. Yesterday, Ms. P could not
remember where she was in her own room. She was seen three days ago by her primary doctor
, NRNP 6665 SOAPNOTE SAMPLE
where her blood pressure was noted to be elevated; hence, her prescription for her blood pressure
medication, Hydrochlorothiazide, was increased to 50 mg daily. No contributing trauma nor fall
were reported by son. No changes in diet or routine regimens were reported.
Current Medications:
Multivitamin daily
Losartan 50 mg daily
Hydrochlorothiazide 50 mg daily
Fish Oil 1 tablet daily
Glyburide 5 mg daily
Metformin 500 mg twice a day
Donepezil 10 mg daily
Alendronate 70 mg orally once a week
Allergies: Atorvastatin
Past Medical History:
Dementia, Hypertension, Diabetes, Osteoporosis, Chronic Allergic Rhinitis
Immunization status unknown
Last seen by primary physician 3 days ago
Social and Substance History:
Lives at home with son. Unknown tobacco, alcohol, and drug use.
Family History:
Family history unknown
Surgical History:
No surgical history was reported
