NUR 545 Module 4 SOAP Note Example

Course	NUR 545 Advanced Health and Literacy Assessment
Module	Module 4
Paper type	Focused SOAP note with examination findings
Length	About 1,050 words, 6 pages
Format	APA 7 student paper
School	Southern New Hampshire University
Program	MSN
Updated	September 2026

Free sample paper for NUR 545 Module 4

SOAP Note: Focused Visit for Newly Diagnosed Type 2 Diabetes in a Night-Shift Worker

[Student Name]

Southern New Hampshire University

NUR 545: Advanced Health and Literacy Assessment

SOAP Note

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

What this page is doingA SOAP note title names the visit type, the diagnosis and the feature of the patient that most changes the plan.

SOAP Note: Focused Visit for Newly Diagnosed Type 2 Diabetes in a Night-Shift Worker

S: Subjective

Chief concern: follow-up of high blood sugar found at a workplace screening. 58-year-old man, night-shift warehouse order picker, referred after workplace screening. Three months of thirst, nocturia equivalent (wakes three times per daytime sleep), late-shift blurred vision and about 4 kg unintended weight loss. Denies foot numbness or sores, chest pain, dyspnea or syncope. Prior pharmacy kiosk blood pressure reading "up there"; no follow-up. Takes ibuprofen 400 mg two to three times weekly for back pain. No known drug allergies. Family history of type 2 diabetes and stroke (mother) and myocardial infarction at 61 (father). Former smoker, 20 pack-years, quit 10 years ago; four beers on weekend days. One large meal around 3 a.m.; two 20-ounce regular sodas per shift. Reports learning best "when somebody shows me"; Newest Vital Sign 2 of 6 at intake.

What this page is doingThe subjective section is compressed from the full history to what this visit needs, and every item is something the patient reported or a prior result, not an examiner's finding.

O: Objective

Blood pressure 152/94 mm Hg seated, left arm, after five minutes' rest; repeat 148/92 mm Hg after two minutes. Pulse 84 and regular; respirations 16; afebrile at 36.8°C; saturating 98% breathing room air. Measured 175 cm tall and 98 kg (body mass index 32.0). Waist circumference 110 cm.

General: alert, conversational, in no distress. Skin: velvety, darkened skin over the posterior neck and in each axilla; 2 cm healing abrasion on the right forearm without redness or drainage. Eyes: pupils equal and reactive; undilated fundoscopic view limited, no hemorrhages seen. Neck: no thyromegaly; no carotid bruits. Heart: S1 and S2 crisp at a regular rate; no added sounds or murmurs heard at any listening post. Lungs: clear to auscultation throughout. Abdomen: obese, soft, nontender.

Feet: skin intact; calluses under both first metatarsal heads; nails thickened but trimmed; no deformity. Pedal pulses (dorsalis pedis, posterior tibial) palpable at 2+ on each side. 10-g monofilament sensation present at all sites tested on both feet; vibration with 128-Hz tuning fork present at both great toes. Ankle reflexes 2+ and symmetric.

Laboratory (drawn at intake): hemoglobin A1C 8.4%; fasting plasma glucose 172 mg/dL; estimated glomerular filtration rate 84 mL/min/1.73 m²; urine albumin-to-creatinine ratio 48 mg/g; LDL cholesterol 142 mg/dL, HDL 36 mg/dL, triglycerides 260 mg/dL; alanine aminotransferase normal.

What this page is doingObjective data are organized by vital signs, examination by region and laboratory values, with technique noted where it affects interpretation, such as rested and repeated blood pressure.

A: Assessment

1. Type 2 diabetes mellitus, newly diagnosed, with hyperglycemia (A1C 8.4%, symptomatic). Acanthosis nigricans supports insulin resistance. No evidence of neuropathy or foot ulceration; retinopathy not yet assessed.

2. Hypertension, stage 2 by ACC/AHA criteria (average 150/93 mm Hg on two readings; needs confirmation at a second visit or with home readings) (Whelton et al., 2018).

3. Moderately increased albuminuria (urine albumin-to-creatinine ratio 48 mg/g, requires repeat to confirm) with preserved kidney function; increases cardiovascular and kidney risk; regular NSAID use is a contributing concern.

4. Dyslipidemia (LDL 142 mg/dL, low HDL, high triglycerides) in a patient with diabetes and multiple risk factors.

5. Limited health literacy with low numeracy (NVS 2 of 6; SILS often), affecting self-management teaching.

Also noted: obesity, class 1 (BMI 32.0); former tobacco use; callus formation at pressure points.

What this page is doingThe assessment is a numbered, prioritized problem list, each with its supporting data and any need for confirmation, which is what graders look for in advanced practice documentation.

P: Plan

1. Diabetes: start metformin 500 mg once daily with the 3 a.m. work meal, increasing weekly as tolerated toward 1,000 mg twice daily with his two largest meals; given albuminuria and cardiovascular risk, discuss adding an SGLT2 inhibitor or GLP-1 receptor agonist at follow-up (American Diabetes Association Professional Practice Committee, 2025). Refer to diabetes self-management education with a request for a hands-on, demonstration-based format. Dilated eye examination referral. Home glucose meter taught by demonstration (Module 5 teach-back); initial goal of checking before the work meal on three nights a week.

2. Hypertension and albuminuria: start lisinopril 10 mg daily at the start of his waking day (about 2 p.m.); basic metabolic panel in 1 to 2 weeks to check potassium and creatinine; repeat urine albumin-to-creatinine ratio in 3 months. Home blood pressure monitor demonstrated.

3. Dyslipidemia: start atorvastatin 40 mg daily with the lisinopril, consistent with statin therapy for adults 40 to 75 with diabetes (Grundy et al., 2019).

4. Stop regular ibuprofen; acetaminophen for back pain, with the daily maximum shown on the bottle rather than in writing.

5. Health literacy: all teaching by demonstration and teach-back; one written sheet only, a picture-based schedule of when to take each tablet in relation to his shift; daughter included by his choice. Replace sodas with water or diet drinks as the single first diet change.

6. Vaccines: tetanus-diphtheria-pertussis, pneumococcal and influenza as indicated; hepatitis B per diabetes recommendations.

7. Follow-up in 2 weeks for blood pressure, labs and review of meter use; sooner for vomiting, confusion or glucose readings above 300 mg/dL.

What this page is doingEach plan item matches a numbered problem, cites current guidance where drugs are chosen and adapts timing and teaching to the patient's schedule and literacy.

Commentary on the Documentation

Three choices in this note deserve explanation. First, subjective and objective data are strictly separated: the patient's report of high blood pressure appears under S, the measured readings under O, and neither is interpreted until A. Standard texts on examination stress this separation because it lets another clinician judge the evidence independently (Bickley et al., 2021). Second, the assessment is prioritized and each problem carries its evidence, including findings that still need confirmation, such as a single urine albumin result. Third, the plan uses clinical language because this is a record for clinicians, while the teaching it describes will use a different register entirely. The medication schedule written into the plan is anchored to the patient's shift, not to morning and evening, because a plan that assumes a daytime schedule would fail for this patient before it began.

The foot examination deserves particular care in any new diabetes visit. Monofilament testing combined with a second test, such as vibration, identifies loss of protective sensation that patients rarely notice; this patient's normal results, together with his calluses, set a baseline and point to footwear advice rather than urgent referral.

Finally, the note includes safety-net instructions and a short interval to follow-up. Starting three medicines at once in a patient with limited numeracy carries a real risk of confusion, and an ACE inhibitor requires a potassium and creatinine check within weeks. A two-week visit allows the team to confirm the blood pressure, review the laboratory results, watch him use the meter and ask, through teach-back, how he is taking each tablet. If any part of the schedule has not worked on his shifts, the plan can be simplified before habits form.

What this page is doingA brief commentary shows the reasoning behind documentation choices, which many rubrics reward as evidence of advanced practice thinking.

References

American Diabetes Association Professional Practice Committee. (2025). 9. Pharmacologic approaches to glycemic treatment: Standards of care in diabetes 2025. Diabetes Care, 48(Suppl. 1), S181-S206. https://doi.org/10.2337/dc25-S009

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.

Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A., . . . Yeboah, J. (2019). 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 139(25), e1082-e1143. https://doi.org/10.1161/CIR.0000000000000625

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison Himmelfarb, C., DePalma, S. M., Gidding, S., Jamerson, K. A., Jones, D. W., MacLaughlin, E. J., Muntner, P., Ovbiagele, B., Smith, S. C., Spencer, C. C., Stafford, R. S., Taler, S. J., Thomas, R. J., Williams, K. A., . . . Wright, J. T. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension, 71(6), e13-e115. https://doi.org/10.1161/HYP.0000000000000065

What the NUR 545 Module 4 instructions ask for

The documentation assignment in NUR 545 usually asks for a SOAP note or similar focused note based on a scenario or simulated patient. Prompts commonly require subjective data from the history, objective findings from a focused examination with vital signs and relevant tests, an assessment with a prioritized problem list or differential diagnosis, and a plan with evidence-based interventions, education and follow-up. Many sections also ask you to show how health literacy shaped the plan. Notes are often two to four pages, with an APA reference list for the guidelines you cite. Write the note in clinical language and standard abbreviations your instructor accepts, and keep patient-facing wording for the education materials. Check whether your section wants a differential diagnosis listed even when the diagnosis is already established.

How this NUR 545 Module 4 soap note example is built

The sample is a focused SOAP note for a composite 58-year-old with new type 2 diabetes. The subjective section condenses the history to what this visit needs. The objective section records rested and repeated blood pressure, measurements, a regional examination including a full diabetic foot exam and laboratory results. The assessment lists five prioritized problems, each with supporting data and any need for confirmation. The plan matches each problem, cites current diabetes, blood pressure and cholesterol guidance, fits medication timing to a night shift and specifies demonstration-based teaching. A short commentary explains the documentation choices. Four real sources support the note: the 2025 ADA standards, the blood pressure and cholesterol guidelines and a standard examination text.

Where the NUR 545 Module 4 rubric puts the points

SOAP notes are generally graded on the accuracy and completeness of subjective and objective data, the separation between them, the quality of the assessment, the evidence base of the plan, individualization and professional documentation. The separation criterion is strict: a symptom recorded as an objective finding, or an interpretation placed in the subjective section, costs points. Assessment credit rises when problems are prioritized and supported by specific data. Plans earn full credit when each problem has a matching intervention grounded in current guidance, with education and follow-up, and when the plan fits the patient's life and literacy rather than a generic template.

NUR 545 Module 4 help: the mistakes that cost points

SOAP notes commonly go wrong by copying the whole history into S, by recording findings without technique where technique matters, or by writing an assessment that lists diagnoses without the data behind them. Another frequent gap is a plan that ignores the patient's schedule, resources or literacy. Keep S and O strictly separate, examine and record what the problem requires, number and prioritize the assessment, match every plan item to a problem and cite current guidelines. Show how literacy shaped teaching. Proofread for abbreviations your program does not allow. If your scenario involves a different condition, we can write a focused SOAP note around it.

Get NUR 545 Module 4 written to your instructions

Send your scenario or case data, your program's SOAP template and the rubric. A focused SOAP note with separated data, a prioritized assessment and a guideline-based, individualized plan is ready in 24 to 48 hours, and the first one is free. The paper above is an original model document written by our desk, not a submitted student paper and not an official Southern New Hampshire University document.

More NUR 545 papers and related MSN samples

NUR 545 Module 4 questions, answered

Where can I find a free NUR 545 Module 4 SOAP Note sample?

The complete note on this page is free to read: a focused SOAP note for a composite adult with new type 2 diabetes, with separated data, a foot exam, labs, a prioritized assessment, a literacy-aware plan and four real sources.

What goes in the subjective versus objective section?

Subjective holds what the patient or family reports, including symptoms and history. Objective holds measured and observed findings, such as vital signs, examination results and lab values.

How should a diabetic foot exam be documented?

Record skin, calluses, nails and deformity, pedal pulses, 10-g monofilament results and one other sensory test such as vibration, plus reflexes if tested.

How do I prioritize an assessment in a SOAP note?

Number the problems by clinical importance and urgency, and list the supporting data for each, including findings that still need confirmation.

How can health literacy appear in a SOAP note?

As a documented problem with its screening result, and in the plan through specific teaching methods such as demonstration, teach-back and simplified written materials.