This page holds a finished NU 610 Unit 3 SOAP note covering one episodic complaint, with the four parts bounded and every plan item traceable backward. Searches like "nu 610 unit 3 assignment example", "nu610 unit 3 sample" and "nu 610 unit 3 example" land here.
The NU 610 Unit 3 SOAP note, in full
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
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.
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.
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.
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
What a finished NU 610 Unit 3 SOAP note looks like
The finished note is short, dense and unmistakably a chart entry. The subjective part carries the complaint, a compact present illness and only the history relevant to today, including the negatives the complaint demands. The objective part holds vitals and the examination actually performed, described in the same physical terms the course has been drilling, plus any point of care results. The assessment names the problem with a status attached, such as new, worsening or stable, and it is written in one or two sentences that use only data already sitting above it. The plan runs one block per problem and covers orders, prescriptions with dosing, patient education in plain language, and a return interval with the reason for that interval visible.
How a NU 610 Unit 3 example is structured
The example is arranged so that each part can only use material the part above it earned. Subjective comes first and is bounded strictly: reported symptoms, reported history, reported negatives, nothing measured. Objective follows with vitals, the examination and any results, and it never contains an opinion about what those findings mean. The assessment sits third and is where interpretation is finally allowed, stated as a named problem with a status rather than as a paragraph of reasoning, since the reasoning course handles argument at length. The plan comes last and is written per problem rather than as a single list, so a reader can see which order belongs to which issue. Return precautions and follow-up close the note. The whole document is scannable in under a minute, which is the point of the format.
Reported and observed kept apart
What the patient said and what the clinician measured live in separate parts, and no finding appears in both, which is the discipline the format exists to enforce.
One episodic problem, carried through
The note follows a single complaint from opening line to return interval, rather than sweeping up every chronic issue the patient happens to carry.
An assessment built from data above it
The named problem uses only findings already recorded, so nothing arrives in the assessment that the reader has not already seen.
A plan written problem by problem
Orders, prescriptions, education and referral sit in a block attached to the problem they belong to instead of pooling into one undifferentiated list.
Education and follow-up made concrete
The note states what the patient was told, in words a patient would understand, and when to return along with what should trigger returning sooner.
Where marks go in NU 610 Unit 3
Notes lose marks at the seams. Examination findings written into the reported part, or patient statements written into the observed part, cost the criterion about documentation structure before anything else is read. New information appearing for the first time in the assessment is the second leak, because it means the note concluded something the record never showed. Plans that name a drug class with no dose, route or duration give up prescribing points, and a follow-up written as return as needed gives up the plan criterion for the same reason. Notes that quietly expand into every chronic problem the patient has stop being episodic and lose focus. The strongest versions attach one line of teaching and one red flag to every problem they name.
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.
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.