NURS 5220 SOAP NOTE ASSIGNMENT 1 | 2026 UPDATED | WITH
COMPLETE SOLUTIONS - UTA.
Soap Note Assignment
Dhruva Patel
The University of Texas at Arlington
NURS 5220 Advanced Health Assessment and Diagnostic Reasoning
Lindsay Hermsdorfer, DNP, APRN, FNP-C
September 7, 2025
, SOAP Note Form
S/ Identifying Information: (initials, Family Hx:
age/DOB, gender, reliability)
AM. A.M is the first child reported by her mother. Her mom
3year old and dad are married and has3 children together now. AM
Female has is up to date per the mom on her immunizations . Her
patient came to clinic with her mom reports that family has set of twins who were
mother who considered to be premature and had required extensive NICU time. Mother
reliable historians. reports that last week they had second infant came home
who requires G tube and oxygen. No sickness at home
reported by parents. No parental smoking in house.
Personal/Social Hx:
Chief Complaint/RFE: A.M. stays with her mom, dad and siblings. The family
A.M. is sick and reports lives upstairs in a tight 2- bedroom apartment. Mom was
complaints of “fever and sore working before pregnancy but does not work since preg-
throat.” nancy. Dad works outside the home in retail and is gone
for long hours.
AM was the first child born to this couple. She was a term
birth. She has been in daycare since she was 6 months. In
the past month had to move to a new day care. Mom re-
ports that she is usually playful but lately had notice some
regression and crying due to new daycare. She “eats a tod-
dler diet, drinks from a cup, speaks well with her friends
and family, is normally playful”.
HxPresentlliness: (7 Variables Mom reports that her friend’s child who is in the same
but do not list as such) class was given an antibiotic for the same symptoms last
week.
The patient A.M. is 3 year old came in with “fever and sore throat” to the clinic with her
mother. Mother states the symptoms started 3 days ago when she came home from daycare
with a mild runny nose. Patients mother also reports that that the nasal drainage has in-
creased, she also developed a cough and sore throat. As per mother the nasal drainage was
clear at the beginning but today was yellow and thick”. Patients mom states that she also has
noticed change in her voice and low grade fever of 103.1 since last night when she came
from day care. Patients mom states that she has gave Motrin (7ml ) for fever. As per mother
A.M. woke up this morning later than normal, has not had her normal energy she had about
2 ounces of milk, no food intake today, she is irritable and wants to be held.
CURRENT HEALTH
Medications: Mom reports Patient was given Motrin 7 ml last night for high fever. Mom
reports that A.M does not take any medications routinely.
Allergies: Mom reports no known allergies.
Last PE & Screenings: Mom reports AM was seen in clinic 2 months ago for her 3-year-old well child. She also
has had routine well exams since birth in this clinic.
Immunization Status: up to date for her age
COMPLETE SOLUTIONS - UTA.
Soap Note Assignment
Dhruva Patel
The University of Texas at Arlington
NURS 5220 Advanced Health Assessment and Diagnostic Reasoning
Lindsay Hermsdorfer, DNP, APRN, FNP-C
September 7, 2025
, SOAP Note Form
S/ Identifying Information: (initials, Family Hx:
age/DOB, gender, reliability)
AM. A.M is the first child reported by her mother. Her mom
3year old and dad are married and has3 children together now. AM
Female has is up to date per the mom on her immunizations . Her
patient came to clinic with her mom reports that family has set of twins who were
mother who considered to be premature and had required extensive NICU time. Mother
reliable historians. reports that last week they had second infant came home
who requires G tube and oxygen. No sickness at home
reported by parents. No parental smoking in house.
Personal/Social Hx:
Chief Complaint/RFE: A.M. stays with her mom, dad and siblings. The family
A.M. is sick and reports lives upstairs in a tight 2- bedroom apartment. Mom was
complaints of “fever and sore working before pregnancy but does not work since preg-
throat.” nancy. Dad works outside the home in retail and is gone
for long hours.
AM was the first child born to this couple. She was a term
birth. She has been in daycare since she was 6 months. In
the past month had to move to a new day care. Mom re-
ports that she is usually playful but lately had notice some
regression and crying due to new daycare. She “eats a tod-
dler diet, drinks from a cup, speaks well with her friends
and family, is normally playful”.
HxPresentlliness: (7 Variables Mom reports that her friend’s child who is in the same
but do not list as such) class was given an antibiotic for the same symptoms last
week.
The patient A.M. is 3 year old came in with “fever and sore throat” to the clinic with her
mother. Mother states the symptoms started 3 days ago when she came home from daycare
with a mild runny nose. Patients mother also reports that that the nasal drainage has in-
creased, she also developed a cough and sore throat. As per mother the nasal drainage was
clear at the beginning but today was yellow and thick”. Patients mom states that she also has
noticed change in her voice and low grade fever of 103.1 since last night when she came
from day care. Patients mom states that she has gave Motrin (7ml ) for fever. As per mother
A.M. woke up this morning later than normal, has not had her normal energy she had about
2 ounces of milk, no food intake today, she is irritable and wants to be held.
CURRENT HEALTH
Medications: Mom reports Patient was given Motrin 7 ml last night for high fever. Mom
reports that A.M does not take any medications routinely.
Allergies: Mom reports no known allergies.
Last PE & Screenings: Mom reports AM was seen in clinic 2 months ago for her 3-year-old well child. She also
has had routine well exams since birth in this clinic.
Immunization Status: up to date for her age
