Chelsea Warren Type 1 Diabetes Shadow health SOAP Note

SOAP NoteActivity Time: 8 min
Subjective Documentation:
Student Response: Chelse reports feeling better and ready to go home. She was diagnosed with DKA 2 days ago She was having nausea and vomiting before her father brought her to the ED. Chelsea reports that she had been feeling unwell for 10 days before the hospitalization. She reported having excessive thirst and frequent urination for about 10 days before the DKA episode Chelsea Warren Type 1 Diabetes Shadow health SOAP Note.

Model Note: CC: “Diabetes” HPI: Chelsea Warren is an 11-year-old Caucasian female hospitalized with new-onset type 1 diabetes. This is day 3 of her hospitalization. She is a good historian and able to answer questions appropriately. Her father is present in the room with her. She is due to be discharged home today. Chelsea Warren Type 1 Diabetes Shadow health SOAP Note. Chelsea was brought to the ED at 8:30pm 3 days ago by her father two days ago with dizziness, vomiting, and lethargy. She wasn’t feeling well during a horseback riding lesson and hadn’t been feeling well for the past few days. She was diagnosed with Diabetic Ketoacidosis and Diabetes Mellitus 1. She has admitted with a blood sugar above 500 mg/dL PMH: No previous hospitalizations. Nearsightedness diagnosed at age 8. Wears corrective lenses. Up to date on immunizations PSH: No previous surgeries Allergies: NKDA Medications: Started during hospitalization- 0.9% NaCl IV continuous 100ml/hr Insulin glargine – 5 units HS Insulin lispro – sliding scale AC BG 125-174 = 1 unit BG 175-224 = 2 units BG 225-274 = 3 units…Chelsea Warren Type 1 Diabetes Shadow health SOAP Note

Chelsea Warren Focused Exam: Type 1 Diabetes Shadow health Documentation
Documentation / Electronic Health Record

Nursing Note
Student Documentation Model Documentation
Patient Status
Chelsea is currently stable. She reports feeling better. No current nausea or vomiting She is alert and well oriented She expressed a desire to go home She said she has not administered insulin on her own or performed glucose monitoring on her own

Chelsea’s current condition is stable. She is feeling better than she has been lately. No current nausea or vomiting. Chelsea is alert and curious, and expressed an eagerness to go home. She said that she has not administered her own insulin yet, or done her own glucose monitoring.

History of Present Illness
The patient had diabetic ketoacidosis two days ago, when she was hospitalized. When she was horseback riding, she started being nauseous and vomited in her father’s car. The father brought her to the ED and she was diagnosed with DKA and type 1 diabetes. Her blood glucose is now stable. Before the DKA, Chelsea was feeling sick for about 10 days. The father reported that she had lost about 5 pounds in 2 weeks. Chelsea Warren Focused Exam: Type 1 Diabetes Shadow health Documentation Chelsea has been having increased thirst and excessive urination before the DKA.

Chelsea had diabetic ketoacidosis two days prior. She was at a horseback riding lesson and started feeling nauseated; when her dad picked her up she threw up in his car. That evening, Ned said that his daughter seemed really out of it and was not acting like herself. He brought her to the ED, and she was diagnosed with DKA and type 1 diabetes. Chelsea’s blood glucose is more stable now. Prior to the DKA, Chelsea said she felt sick for about 10 days. Her dad, Ned, said that she lost five pounds in the two weeks since he’s seen her. She experienced increased thirst and increased urination / a higher volume of urine during the 10 days leading up to her DKA. Chelsea said her mother thought she was “going through a growth spurt” or coming down with a cold Chelsea Warren Focused Exam: Type 1 Diabetes Shadow health Documentation.

Assess Patient Knowledge
Chelsea is…Chelsea Warren Focused Exam: Type 1 Diabetes Shadow health Documentation


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