SOAP note case study with ICD-10 coding
Analyse the week's case study and build a SOAP note covering disease prevention, health promotion and acute care, with scholarly evidence no older than five years, a scientific rationale for each nursing action, and the ICD-10 classification, in three to four pages.
Editorial process
Last reviewed · August 13, 2026
The instruction that decides the note
One instruction in this prompt does more work than any other: if information is not in the scenario, treat it as normal, and if it should be abnormal given the disease process, write what you would expect to find. That is permission to complete the note and a test at the same time. Filling gaps with normal findings is easy; knowing which gaps should not be filled with normal findings requires you to have understood the pathophysiology. If the case points toward a condition with characteristic findings, those findings belong in the objective section even though the vignette omitted them, and an assessor comparing your note against the diagnosis will look precisely there. So work out the likely diagnosis first, before writing a word of the note, and then populate the subjective and objective sections consistently with it, rather than transcribing the vignette and bolting a diagnosis onto the end of it.
The plan is where the marks concentrate, and the prompt shapes it in three ways. It must cover disease prevention, health promotion and acute care, which means a note that only treats the presenting problem has answered a third of the question. It must rest on scholarly evidence no older than five years, with government sources named as acceptable, so each element of the plan needs a citation rather than a general reference list. And it demands a detailed scientific rationale justifying the inclusion of that evidence, which is a step beyond citing: say why this guideline applies to this patient, not merely that it exists. The ICD-10 requirement is easy to get wrong through imprecision, since the classification rewards specificity, so code to the highest level of detail the documentation supports and state the code with its full description. Keep the whole note within three to four pages and use the template supplied.
Likely learning objectives
Inferred from the brief — check these against your own rubric.
- 01Complete a clinical vignette with findings consistent with the likely disease process.
- 02Distinguish subjective from objective data reliably.
- 03Build a plan that addresses prevention and promotion as well as acute care.
- 04Attach a scientific rationale to each nursing action rather than to the note as a whole.
- 05Assign an ICD-10 code at the level of specificity the documentation supports.
Read the full question
Review every instruction before using the planning guidance that follows.
Course-wide instructions that accompany this question
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Turn the brief into deliverables
- 01A completed SOAP note using the supplied template.
- 02Subjective and objective sections consistent with the case and the disease process.
- 03An assessment supported by the documented findings.
- 04A plan covering disease prevention, health promotion and acute care.
- 05Current scholarly evidence, no older than five years, supporting the nursing actions.
- 06A detailed scientific rationale justifying the inclusion of that evidence.
- 07The ICD-10 classification for the case.
- 08Three to four pages excluding title and references, named in the required file format.
Subjective through plan, then the code
Subjective
History, chief complaint and review of systems, completed consistently with the likely diagnosis.
Objective
Examination and results, including findings the disease process predicts.
Assessment
The diagnosis and differentials, each supported by documented findings.
Plan: acute care
Immediate management with rationale and current evidence.
Plan: prevention and promotion
Screening, immunisation, risk reduction and education appropriate to the patient.
ICD-10 classification
The code, its full description, and why the documentation supports that level of specificity.
Evidence attached to actions
Recommended databases
- PubMed
- CINAHL
- CDC
- AHRQ
- WHO ICD browser
- USPSTF recommendations
Search sequence
- 1.Identify the likely diagnosis from the vignette before writing any section.
- 2.Read the current clinical guideline for that condition, published within five years.
- 3.Check the preventive service recommendations that apply to this patient's age and risk.
- 4.Look up the ICD-10 code and read the inclusion notes for the specific subcategory.
- 5.Find evidence for each planned nursing action rather than for the diagnosis alone.
Reference shortlist
These are authoritative starting points, not a ready-made bibliography. A qualified reviewer must confirm that each source fits the assignment and supports the claim beside which it is cited.
Nothing here is cleared for citation until you have read it.
- 01
SOAP Notes
StatPearls, NCBI Bookshelf · 2023
What belongs in each section, and the subjective and objective boundary the note is graded on.
- 02
International Classification of Diseases (ICD)
World Health Organization · 2024
The classification's structure and the principle of coding to the highest available specificity.
- 03
ICD-10
Centers for Medicare & Medicaid Services · 2024
The United States clinical modification and its code sets, which is what the prompt asks you to use.
- 04
Nursing Process
StatPearls, NCBI Bookshelf · 2023
Keeps assessment and planning distinct, which is what makes the rationale requirement answerable.
Review before submission
Common mistakes
- Transcribing the vignette and adding a diagnosis without making the sections consistent.
- Recording normal findings where the disease process predicts abnormal ones.
- Writing a plan that treats the acute problem only.
- Citing evidence without explaining why it applies to this patient.
- Choosing an unspecified ICD-10 code when the documentation supports a specific one.
- Using sources older than five years when the prompt sets that limit.
Submission checklist
- Subjective and objective sections are internally consistent with the assessment.
- Findings expected from the disease process appear even where the vignette omitted them.
- The plan addresses prevention, promotion and acute care separately.
- Each nursing action carries a rationale and a citation.
- All sources are within five years.
- The ICD-10 code is stated with its full description and is as specific as the record allows.
- The note uses the supplied template and is three to four pages.
- The file is named in the format the prompt specifies.
Use this guide to plan and review your own work. Follow your institution's rules and read our academic-integrity policy.
Written by
Aaron Bishop
MA, Education
assignment interpretation and research-methods coaching across disciplines
Aaron leads the EssayCrackers editorial desk. He works on how assignment briefs are read — what a rubric is actually asking for, and where students most often answer a different question than the one set.
Reviewed by
Dr. Nathan Cole
PhD, Rhetoric & Composition
Argumentation and thesis development
Nathan teaches first-year composition and directs a university writing center. He reviews EssayCrackers guides for argumentative soundness and citation accuracy.