NURS 6512 Week 8 Abdominal SOAP Note Audit Example

Course	NURS 6512 Advanced Health Assessment and Diagnostic Reasoning
Week	Week 8
Paper type	Abdominal SOAP note audit
Length	About 1,110 words, 7 pages
Format	APA 7 student paper
School	Walden University
Program	Master of Science in Nursing (MSN)
Updated	October 2026

Free sample paper for NURS 6512 Week 8

Does the Data Support the Diagnosis? An Audit of a SOAP Note for Postprandial Right Upper Quadrant Pain in a 45-Year-Old Woman

Student Name

College of Nursing, Walden University

NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

Instructor Name

Month Day, Year

What this page is doingThe title is phrased as the audit's governing question. An audit that announces its question on the title page commits itself to answering it with a verdict, which is what separates this document from a general commentary on the note.

Does the Data Support the Diagnosis? An Audit of a SOAP Note for Postprandial Right Upper Quadrant Pain in a 45-Year-Old Woman

The Supplied Note

The note under audit was constructed for teaching, as was its patient. It reads: "S: 45 y/o F with RUQ pain x 1 day, worse after eating. Hx of similar pain. Nausea, no vomiting. O: T 98.9, HR 88, BP 132/80. Abd soft, tender RUQ, bowel sounds present. A: Acute cholecystitis. P: Refer to ER for surgical eval." The audit tests one question: does the data on the page support the diagnosis at the bottom of it? It proceeds in four steps: a status review of the subjective data, a review of the objective data, a support table, and a verdict with tests and a revised differential.

Subjective Review with Status

Each element that bears on right upper quadrant pain is marked present, absent, or never asked. The distinction between absent and never asked matters: an absent finding is evidence, while an unasked question is a gap.

Relation to meals: present, but vague. "Worse after eating" does not specify fatty meals, the delay between eating and pain, or whether the pain is constant or comes in waves.

Duration and course: partly present. One day is recorded, but there is no statement of whether the pain has been continuous for 24 hours or has come and gone. Pain lasting more than about six hours without relief points away from simple biliary colic and toward inflammation.

Radiation: never asked. Radiation to the right shoulder or scapula supports a biliary source; radiation straight through to the back suggests pancreatitis or a posterior ulcer.

Fever and chills: never asked. The recorded temperature is only a moment in time.

Jaundice, dark urine, pale stools: never asked. These separate simple gallbladder disease from obstruction of the common bile duct.

Nausea: present. Vomiting: absent.

Prior episodes: present but undescribed. "Hx of similar pain" does not say how many episodes, how long they lasted, or whether imaging was ever done.

Other items never asked: alcohol use, use of nonsteroidal anti-inflammatory drugs, last menstrual period and possibility of pregnancy, cardiac risk factors, cough or breathlessness, and medications.

What this page is doingWriting the review as a status list, one element per line, makes the most important documentation point visible: most of the gaps are questions never asked, not findings recorded as negative. Graders on this week look for exactly that distinction, and the list format lets the support table below draw on each item directly.

Objective Review

The note records vital signs, then "abd soft, tender RUQ, bowel sounds present." Three problems stand out. First, the sequence is wrong for the abdomen. Inspection should come first, followed by auscultation before percussion and palpation, because palpation can alter bowel sounds (Bickley et al., 2021). The note lists palpation findings before auscultation, and nothing indicates that inspection was performed; jaundice, distension, and scars from prior surgery would all be visible.

Second, the named sign that the diagnosis depends on is missing. Murphy's sign, inspiratory arrest during deep palpation under the right costal margin, is the bedside finding most associated with acute cholecystitis, yet the note does not say whether it was sought or what it showed. Tenderness in the right upper quadrant is not the same finding. Third, the note records no percussion of the liver span, no assessment for guarding or rebound, no costovertebral angle tenderness, and no examination of the lungs or heart. Given that referred causes of right upper quadrant pain arise above the diaphragm, a lung and cardiac examination belongs in this note.

The Support Table

The note's diagnosis, acute cholecystitis, predicts a set of findings. Each is listed with its status in the note.

Continuous right upper quadrant pain for more than six hours: missing. Duration recorded, character not.

Fever or elevated temperature: contradicted weakly. Temperature 98.9 F, though a single reading does not exclude fever.

Positive Murphy's sign: missing.

Right upper quadrant tenderness: present.

Guarding or a palpable gallbladder: missing.

Elevated white blood cell count or C-reactive protein: missing. No laboratory data.

Ultrasound showing gallbladder wall thickening, pericholecystic fluid, or a sonographic Murphy's sign: missing. No imaging.

Of seven predicted findings, one is present, one is weakly contradicted, and five are missing. The note's conclusion therefore rests on a single finding, tenderness, that is shared by nearly every diagnosis on the revised differential below. A systematic review of the clinical examination for acute cholecystitis found that no single history or examination finding was sufficient to establish or exclude the diagnosis, and that laboratory tests and imaging are needed (Trowbridge et al., 2003).

What this page is doingThe table is the center of the audit. It converts a judgment about whether the note seems reasonable into rows that anyone can check, and the tally at the end states the result numerically. Citing the evidence on the accuracy of bedside findings then explains why a diagnosis resting on tenderness alone cannot stand.

Verdict and Tests

The diagnosis of acute cholecystitis is not supported by the data recorded. It remains possible, and the referral may have been prudent, but the note does not show why. The available history, with recurrent pain after eating, nausea, and no documented fever, is at least as consistent with biliary colic from symptomatic gallstones as with inflammation of the gallbladder, and several important alternatives were never tested.

Five tests would settle what the note leaves open. Right upper quadrant ultrasound is the first-line imaging study, since it shows stones, wall thickening, and pericholecystic fluid and allows a sonographic Murphy's sign (Dains et al., 2020). A complete blood count and C-reactive protein would show whether there is an inflammatory response. Liver function tests, including bilirubin and alkaline phosphatase, would show whether the common bile duct is obstructed. Serum lipase would address pancreatitis. A urine pregnancy test is needed in a woman of reproductive age before imaging and treatment decisions, and an electrocardiogram would exclude an inferior myocardial infarction presenting as upper abdominal pain.

Revised Differential

1. Biliary colic from symptomatic cholelithiasis. Supported by recurrent postprandial pain, nausea, and absent documented fever. It would be favored if the pain lasts under six hours and resolves between episodes, and ultrasound shows stones without wall thickening.

2. Acute cholecystitis. Supported by right upper quadrant tenderness and prior episodes. It would require continuous pain, a positive Murphy's sign, fever or leukocytosis, and ultrasound signs of inflammation.

3. Choledocholithiasis. A stone in the common bile duct would be supported by jaundice, dark urine, or pale stools, none of which were asked about, and by elevated bilirubin and alkaline phosphatase.

4. Peptic ulcer disease. Supported by pain related to meals and a history of recurrent episodes. It would be favored by nonsteroidal anti-inflammatory drug use, epigastric rather than right-sided tenderness, and pain relieved rather than provoked by eating.

5. Inferior myocardial infarction, a cause outside the abdomen. Supported only by the location of the pain and the absence of any cardiac history in the note, which means cardiac risk was never assessed. It is ranked last on likelihood but kept on the list because it is dangerous to miss and cheap to exclude with an electrocardiogram. Right lower lobe pneumonia belongs in the same category and is excluded by a lung examination and, if needed, a chest radiograph.

What this page is doingThe revised differential is tied line by line to what the note contains or lacks, so it doubles as a list of the missing data. Including a cause above the diaphragm is a scored element this week: right upper quadrant pain is a classic place for cardiac and pulmonary disease to hide, and an audit that stays inside the abdomen misses an expected point.

References

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.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2020). Advanced health assessment and clinical diagnosis in primary care (6th ed.). Elsevier.

Trowbridge, R. L., Rutkowski, N. K., & Shojania, K. G. (2003). Does this patient have acute cholecystitis? JAMA, 289(1), 80-86. https://doi.org/10.1001/jama.289.1.80

The Walden NURS 6512 Week 8 instructions

The eighth NURS 6512 week asks you to audit a note against its diagnosis. Review subjective and objective data, mark each element present, absent or never asked, map findings to the diagnosis, give a verdict and revise the differential. Impression-based judgments lose marks, so a mapping of findings to the diagnosis is essential. Cite assessment and diagnostic criteria in APA 7. The support table lists what the diagnosis requires and whether the note shows it. A cause outside the abdomen, such as inferior myocardial infarction, belongs on the differential. An audit tests the existing note rather than writing a new one.

Inside the NURS 6512 Week 8 example

The audit runs about three pages and takes the supplied note section by section. Its subjective review checks for the pain's relation to meals, radiation to the shoulder or back, fever, jaundice, changes in urine or stool color, nausea and prior episodes, and marks each as present, absent or never asked. Its objective review looks for inspection, auscultation, percussion and palpation recorded in the sequence the abdomen requires, and for named signs such as Murphy's sign documented with a result. A support table then maps the note's diagnosis against the findings that would be expected if it were right, showing which are present, missing or contradicted. The audit concludes on whether the diagnosis stands, lists the diagnostic tests that would settle it, and offers a revised differential including one cause outside the abdomen. She and the note are both invented.

Where the marks sit in the NURS 6512 Week 8 rubric

Audits lose marks when they judge the note by impression. Saying the assessment seems reasonable, with no mapping of findings to the diagnosis, skips the analysis the week is built around. Missing-item lists that do not distinguish between an element that was negative and one that was never asked blur the most important point about documentation. The examination sequence for the abdomen is specifically graded, and an audit that fails to notice palpation recorded before auscultation misses an expected observation. Named signs cited without their result, or without explaining what a positive result would suggest, earn little. Differentials confined to the gallbladder and its neighbors lose marks for omitting referred causes. Tests listed without the question each would answer read as a standard panel.

NURS 6512 Week 8 help: mistakes that cost marks

Note audits score poorly when they call the assessment reasonable without mapping. Build the support table. A second weakness is treating never asked as absent. Keep them separate. Writers also skip outside causes. Add one. Avoid rewriting the note. Audit it. Name the tests that would settle the question. A row showing that fever, a key criterion, was not present while a positive Murphy sign was never checked reveals the gap clearly. Close with whether the diagnosis stands. Quote each line of the note before marking it.

Get a NURS 6512 Week 8 example written to your instructions

The SOAP note your Week 8 classroom supplies, sent with its prompt and rubric, becomes the subject of an audit built around a support table and a revised differential. There is no charge for a first sample, and delivery takes 24 to 48 hours. The audited note in the example was drafted for teaching and belongs to no patient.

More NURS 6512 papers and MSN samples

NURS 6512 Week 8 questions, answered

What is the support table?

A grid placing the note's diagnosis against the findings it would be expected to produce, each marked present, missing or contradicted. It makes the question of whether the data supports the conclusion something a reader can check line by line. The example builds its verdict from the table, which is why the verdict can be stated in a single sentence.

Why include a cause outside the abdomen?

Because pain felt in the right upper quadrant can arise from the chest, and a differential that stays inside the abdomen can miss a dangerous alternative. The example includes one such cause and names the findings that would raise or lower it. Graders at this level often look for that breadth, and it costs only a line to show.

How is an audit different from a new SOAP note?

An audit evaluates a note someone else wrote rather than producing a fresh one. The example quotes the supplied note, judges each section against what the complaint requires, and tests the conclusion. If your section asks for a rewritten note after the audit, the sample places a corrected version beneath it, still on the composite case.

Where can I find a free NURS 6512 Week 8 sample paper?

The right upper quadrant SOAP note audit is reproduced here with the status review, support table, verdict, tests and revised differential.

Does the data support cholecystitis in NURS 6512 Week 8?

Only partly. The audit finds key criteria absent or never asked, so biliary colic and other causes stay on the differential pending ultrasound.