German Jordanian University
School of Nursing
Intensive Clinical Training I
Summer Semester 2023/2024
SOPE Report
Date:
Student Name: I. D. No.:
1. Background Data:
Patient’s name (Write only initials): ----------- Age:--------- Room/ Bed: -------
Gender: ---------- Marital status: -------------- Occupation: ------------------
Admission Date: -------------------- Medical Diagnosis:--------------------------
Surgical Procedure (If it is completed): ----------------------- Date of Surgery: --------------------
Diet: -------------------------------------- Activity Limitations:--------------------------------
Current Intravenous Therapy: -------------------------------------------------------
2. History of illness:
• Chief Complain
• History of present illness (Include details of what happened since the beginning of the
symptoms? What was the management at homa and ER? if present)
• History of past illness (Such as medical, surgical, allergies history , family etc.): Check
appendix A
3. Patient’s condition upon receiving:
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German Jordanian University
School of Nursing
Intensive Clinical Training I
Summer Semester 2023/2024
SOAP Report
4. Physical Exam (Chose one system according to the patient’s condition and document your findings
whether it is normal and/or abnormal)
A. Inspection:
B. Palpation:
C. Percussion:
D. Auscultation:
5. Vital Signs (With interpretation; why it is abnormal?):
6. Current and planned treatment including any diagnostic procedures (Include details of
results of the diagnostic procedures)
7. Medications:
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German Jordanian University
School of Nursing
Intensive Clinical Training I
Summer Semester 2023/2024
SOAP Report
Medications' name, Classification Action Side Effect Nursing Consideration
dose, route, and (It may take the form of
assessments that must be done
frequency (Include the before, during, or after taking
generic and brand name of the medication)
the medications)
8. Laboratory Tests:
Name of test Results (Include the normal Interpretations Nursing considerations
range) (Why this result is (It may take the form of
abnormal?) assessments that must be done
before, during, or after
completing this test)
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German Jordanian University
School of Nursing
Intensive Clinical Training I
Summer Semester 2023/2024
SOAP Report
➢ ASSESSMENT:
A. Subjective Data (Related to patient’s condition today):
B. Objective Data (Includes the abnormal data only: abnormal vital signs, abnormal conditions upon
receiving, abnormal physical exam, abnormal lab test, and abnormal diagnostic tests):
➢ NURSING DIAGNOSIS:
Nursing diagnosis number (1)
Nursing diagnosis number (2)
➢ PLANNING:
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German Jordanian University
School of Nursing
Intensive Clinical Training I
Summer Semester 2023/2024
SOAP Report
Planning for the first nursing diagnosis:
Goal:
Desired Outcome (or objective according to SMART):
Planning for the second nursing diagnosis:
Goal:
Desired Outcome (or objective according to SMART):
➢ INTERVENTION:
Intervention for the first nursing diagnosis (write at least 3 interventions with the rational):
Intervention for the second nursing diagnosis (write at least 3 interventions with the rational):
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German Jordanian University
School of Nursing
Intensive Clinical Training I
Summer Semester 2023/2024
SOAP Report
➢ EVALUATION:
Evaluation for the first nursing diagnosis:
Evaluation for the second nursing diagnosis:
The End
Appendix A
Draw a pedigree or genogram (graphic family tree):
• Make a list of all your family members.
• Use the sample family tree provided below as a guide to draw your own family tree.
• Write down the age of each member. If it is unknown make a guess (5Os, late 60s).
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German Jordanian University
School of Nursing
Intensive Clinical Training I
Summer Semester 2023/2024
SOAP Report
Draw the Pedigree here:
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German Jordanian University
School of Nursing
Intensive Clinical Training I
Summer Semester 2023/2024
SOAP Report
Page 8 of 10
German Jordanian University
School of Nursing
Intensive Clinical Training I
Summer Semester 2023/2024
SOAP Report
Page 9 of 10
German Jordanian University
School of Nursing
Intensive Clinical Training I
Summer Semester 2023/2024
SOAP Report
How to Collect Your Family Health History*
• Talk to your family. Write down the names of your close relatives from both sides of the
family: parents, siblings, grandparents, aunts, uncles, nieces, and nephews. Talk to these
family members about what conditions they have or had, and at what age the conditions were
first diagnosed. You might think you know about all of the conditions in your parents or
siblings, but you might find out more information if you ask.
• Ask questions. To find out about your risk for chronic diseases, ask your relatives about
which of these diseases they have had and when they were diagnosed. Questions can include:
o Do you have any chronic diseases, such as heart disease or diabetes, or health
conditions, such as high blood pressure or high cholesterol?
o Have you had any other serious diseases, such as cancer or stroke? What type of
cancer?
o How old were you when each of these diseases or health conditions was diagnosed?
(If your relative doesn’t remember the exact age, knowing the approximate age is still
useful.)
o What is your family’s ancestry? From what countries or regions did your ancestors
come to the United States?
o What were the causes and ages of death for relatives who have died?
* Reference:
https://www.cdc.gov/genomics/famhistory/knowing_not_enough.htm?CDC_AA_refVal=https%3A%2F
%2Fwww.cdc.gov%2Ffeatures%2Ffamilyhealthhistory%2Findex.html
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