NU 610 Unit 3 SOAP note Example

Course	NU 610 Advanced Health Assessment
Unit	Unit 3
Paper type	Episodic SOAP note
Length	About 870 words, 6 pages
Format	APA 7 student paper
School	Herzing University
Program	MSN Family Nurse Practitioner
Updated	October 2026

Free sample paper for NU 610 Unit 3

Episodic SOAP Note: Dysuria and Urinary Frequency in a 27-Year-Old Woman

Student Name

Department of Nursing, Herzing University

NU 610: Advanced Health Assessment

Instructor Name

February 23, 2026

What this page is doingAn episodic note announces one complaint in one patient. The title keeps the chronic history out of scope before the note begins, which is the discipline this format is graded on: a note about burning with urination should not become an annual physical.

Episodic SOAP Note: Dysuria and Urinary Frequency in a 27-Year-Old Woman

Subjective

Chief complaint: "It burns every time I pee and I feel like I have to go constantly."

History of present illness: J. M. is a 27-year-old woman, a composite patient built for teaching, seen in a walk-in primary care clinic. Burning with urination began two days ago, the morning after a weekend trip. She reports urinating every 30 to 60 minutes while awake, with small volumes, a strong urge that is hard to delay, and a feeling that her bladder does not empty. She describes lower midline pressure above the pubic bone, 3 out of 10, constant, not radiating. She drank extra water yesterday and took one dose of an over the counter phenazopyridine product last night, which dulled the burning for a few hours and turned her urine orange. She has had one similar episode, three years ago, treated with an antibiotic whose name she does not recall, with full recovery.

Pertinent negatives: she denies fever, chills, back or flank pain, nausea, and vomiting. She denies vaginal discharge, vaginal itching, and pain with intercourse. She denies visible blood in the urine before the phenazopyridine dose. She denies new sexual partners; she has one male partner of two years and uses a levonorgestrel intrauterine device placed 18 months ago. Last menstrual period began 16 days ago and was normal.

Past medical history: none. Surgical history: wisdom tooth extraction at 19. Medications: none daily; one dose of phenazopyridine as above. Allergies: penicillin, with hives as a child; no swelling of the face or throat. Social history: works as a dental hygienist; does not smoke; drinks alcohol socially about twice a month; no drug use.

Review of systems, focused: General, no fever, chills, or fatigue. Genitourinary, as in the present illness; no prior kidney stones. Gastrointestinal, no abdominal pain other than the suprapubic pressure, no diarrhea or constipation. Musculoskeletal, no back pain. Skin, no rash.

What this page is doingEverything in the subjective block is reported, not measured. The negatives chosen are the ones that separate a simple bladder infection from an upper tract infection, a vaginal cause and a sexually transmitted infection, so they are doing diagnostic work. The penicillin reaction is recorded with its reaction, because the plan depends on it.

Objective

Vital signs: T 98.6 F (oral), HR 82 and regular, BP 118/72 (right arm, seated), RR 14, SpO2 99% on room air. Weight 142 lb.

General: well-appearing woman, sitting comfortably, in no distress. Abdomen: flat, bowel sounds present in all four quadrants, soft; mild tenderness to deep palpation in the suprapubic region without guarding or rebound; no tenderness in the other quadrants; no masses. Back: no costovertebral angle tenderness on the right or left with fist percussion, patient seated. Skin: warm, dry, no rash. External genital and pelvic examination deferred because the history contains no vaginal symptoms and the patient declined, which is documented as her choice.

Point of care testing: urine dipstick on a clean catch midstream sample shows leukocyte esterase 2+, nitrite positive, blood trace, protein negative, glucose negative, specific gravity 1.015. Color is orange, consistent with the phenazopyridine dose, which is noted because it can interfere with the color reading of dipstick pads. Urine pregnancy test negative.

What this page is doingThe objective block reports what was examined and measured and stops. It records the phenazopyridine interference next to the dipstick result, a detail graders look for because it shows the writer knows a finding can be unreliable. No sentence here says what the findings mean.

Assessment

Acute uncomplicated cystitis, new episode, in a nonpregnant premenopausal woman with no fever, no flank pain, and no costovertebral angle tenderness. The combination of dysuria and frequency without vaginal discharge carries a high probability of cystitis on history alone, and a positive nitrite with leukocyte esterase supports it (Bent et al., 2002).

Plan

Problem 1, acute uncomplicated cystitis. Nitrofurantoin monohydrate/macrocrystals 100 mg by mouth twice daily with food for 5 days, dispense 10 capsules, no refills. This is a first-line choice for uncomplicated cystitis in women and avoids the beta-lactam class given her penicillin history (Gupta et al., 2011). Urine culture is not ordered because this is an uncomplicated episode with no recurrence in the past year, no recent antibiotic use, and a typical presentation; a culture will be sent if symptoms persist or return within four weeks. Phenazopyridine may be continued for no more than two days for comfort; she was told it changes urine color and can stain contact lenses and fabric.

Education, explained without jargon and checked by having her repeat it back in her own words: take every dose even after the burning stops, drink enough fluid that urine is pale once the orange color clears, and urinate after intercourse. Nitrofurantoin can cause nausea, so take it with a meal. The antibiotic may turn urine darker yellow or brown, which is expected.

Return precautions and follow-up: return the same day or go to urgent care for fever of 100.4 F or higher, shaking chills, pain in the back or side, vomiting that prevents taking the medication, or blood clots in the urine, because these suggest the infection has reached the kidney. Return within 48 to 72 hours if symptoms are not clearly better, at which point a urine culture will be sent. No routine follow-up visit is needed if symptoms resolve. The patient verbalized understanding and agreed with the plan.

What this page is doingThe plan is attached to the single problem it treats, with drug, dose, route, frequency, duration and quantity written out, and the choice is justified against a guideline and the patient's allergy. Return precautions are specific enough that the patient can act on them without calling. A follow-up written as return as needed would have given up the plan criterion.

Documentation Note

This note follows the problem-oriented format first described by Weed (1968), in which each part may use only the material recorded above it: the assessment draws only on the history and dipstick results already documented, and the plan answers only the problem the assessment names. Her other health maintenance needs, including cervical cancer screening status, were not addressed at this episodic visit and are referred to her annual examination.

References

Bent, S., Nallamothu, B. K., Simel, D. L., Fihn, S. D., & Saint, S. (2002). Does this woman have an acute uncomplicated urinary tract infection? JAMA, 287(20), 2701-2710. https://doi.org/10.1001/jama.287.20.2701

Gupta, K., Hooton, T. M., Naber, K. G., Wullt, B., Colgan, R., Miller, L. G., Moran, G. J., Nicolle, L. E., Raz, R., Schaeffer, A. J., & Soper, D. E. (2011). International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases, 52(5), e103-e120. https://doi.org/10.1093/cid/ciq257

Weed, L. L. (1968). Medical records that guide and teach. New England Journal of Medicine, 278(11), 593-600. https://doi.org/10.1056/NEJM196803142781105

NU 610 Unit 3 instructions, in plain terms

The Unit 3 assignment asks you to write a complete SOAP note for a focused, episodic visit, usually from a scenario provided in the classroom. The subjective part should carry the chief complaint in quotation marks, the history of present illness, relevant past history, medications, allergies and a focused review of systems. The objective part should contain only what was measured or observed, including vital signs, the examination and any point-of-care tests. Expect to write an assessment that names the working diagnosis and explains why it fits, and in many sections a short differential is required. The plan should list medications with dose, route, frequency and duration, plus education, follow-up and when to return. Prompts often ask that the plan follow a current guideline with a citation. Keep the language of a chart entry and avoid patient identifiers.

Inside the NU 610 Unit 3 example

The sample note opens with the patient's words for the complaint and a two-day history that includes the pertinent negatives a grader looks for: no fever, no flank pain, no discharge and no chance of pregnancy. The objective section lists vital signs with method and position, an abdominal exam with suprapubic tenderness, no costovertebral angle tenderness and a dipstick positive for leukocyte esterase and nitrite. The assessment states acute uncomplicated cystitis and explains, with a cited likelihood study, why dysuria and frequency without discharge make the diagnosis probable. The plan gives nitrofurantoin 100 mg twice daily for five days with the dispense count, then hydration, return precautions and a note on when a culture would be sent. A closing documentation section explains that each part draws only on material recorded above it, which is the logic of the format.

NU 610 Unit 3 rubric: what full points look like

The Herzing rubric for a SOAP note usually divides points among subjective data, objective data, assessment, plan and documentation quality. Subjective points go to a complete present illness with the pertinent negatives that matter for the complaint. Objective points require measured findings and test results only, with nothing the patient reported slipping into this section. The assessment criterion often carries heavy weight and is scored on whether the diagnosis is supported by the data above it and whether alternatives are considered. Plan points come from correct, guideline-based treatment written with full dosing, along with education and follow-up that match the condition. Documentation quality covers clear organization, standard abbreviations and APA citations for the guideline and the evidence used. Markers frequently check that every plan item traces back to a finding or an assessment statement in the note.

NU 610 Unit 3 help before you submit

A common error is mixing subjective and objective content, for example placing "denies fever" under objective or the temperature under subjective. Some students write an assessment that restates the symptoms instead of naming and supporting a diagnosis. Plans lose points when the medication is listed without dose, frequency, duration or quantity. Another frequent gap is the absence of pertinent negatives, which are what separate simple cystitis from a kidney infection or a sexually transmitted infection. Notes also drop points when education is generic, such as "drink fluids," with no explanation of warning signs. Using a first-line drug without checking allergies or pregnancy status invites a deduction. Finally, guideline citations should be current; a treatment choice supported only by a general website or an outdated source is a weak spot that graders notice.

Get a NU 610 Unit 3 example written to your instructions

Send the Unit 3 instructions and the rubric from your NU 610 classroom, plus the template your section requires and the case you were handed. We produce a custom example inside that template, bounded correctly and traceable from plan back to complaint, and return it in 24 to 48 hours. The first custom sample is free.

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NU 610 Unit 3 questions, answered

Does a NU 610 note need a full differential in the assessment?

Check your instructions, because sections vary and some ask for two or three possibilities with a leading one named. Even where they do, keep it compact. This course is grading whether the record documents an encounter properly, and a page of argument inside a chart entry usually costs more in format points than it gains. Full differential argument belongs to the reasoning course.

Can I use the note template from my clinical site?

Only if your instructions allow it, and only stripped of anything identifying the site or its patients. Many sections supply their own template and grade against it, so an outside format can lose points that have nothing to do with your clinical thinking. When the choice is yours, a plain four part layout with clear headings reads cleanly and is easy for faculty to score.

How much detail belongs in the objective part?

Everything you actually examined, described the way the earlier units required, and nothing you did not. Padding the observed part with systems you never touched is a documentation integrity problem rather than a thoroughness win. If the complaint is a sore throat, a full neurological screen is not expected, but the head, neck and lung findings that bear on it are.

Where can I find a free NU 610 Unit 3 sample paper?

This page holds the whole NU 610 Unit 3 SOAP note for free, with every section, the antibiotic dosing and the margin notes. A different complaint in your scenario is no problem: post it on the request page and you will get a custom note matched to your rubric, free, inside roughly 48 hours.

What goes in the objective part of a NU 610 SOAP note?

Only what you measured or saw: vital signs with method and position, the physical exam findings, and point-of-care results such as a urine dipstick. Anything the patient told you, including what they deny, belongs in the subjective part.

NU 610 Unit 3 SOAP note example