NSG 500 DISCUSSION IV; HEENT ASSESSMENT ON TINA

SOAP NOTES

SOAP charting is the accepted format for charting in most ambulatory care clinics and in practices. SOAP charting includes the following:

S – Subjective: information that the client provides

O – Objective: information that the provider observes

A – Assessment: the diagnoses that the provider determines based on the subjective & objective information

P – Plan: the provider along with the client develops to achieve the desired outcome

Subjective

The subjective portion of the note includes eight components:

1. Chief complaint (CC)

· Collect the following identifiers: date, time, age, race

2. History of Present Illness (HPI)

3. Medical History

4. Surgical History

5. Family History of disease

6. Psychosocial History

7. Review of Systems (ROS)

8. Developmental Milestones (note especially for Pediatric Clients)

Chief Complaint, History of Present Illness, Medical/Surgical History, Family History of Disease & Psychosocial History

The chief complaint is a statement in the client’s own words of why they are being seen by a clinician on that day.

Example: “I have a headache that just won’t go away” x

History of Present Illness

This is a step-by-step story of the current problem or chief complain. It is a detailed explanation and should include specific components in chronological order.

Utilize the components in the following table to obtain the correct information:

COMPONENTS NECESSARY FOR COMPLETE HISTORY OF PRESENT ILLNESS CODIERSMMASSH
Mnemonic	Overview	Specific Questions
C – Chronology	Time frame showing the sequence of events	Have you ever had this BEFORE? How has it changed? What was the order of symptoms?
O – Onset	Occurrence	When did the symptoms start?
D – Description/Duration	Describe it Length of time	What did it FEEL like? How LONG did it last?
I – Intensity	Scale	On a scale from 1-10, how bad is the pain?
E – Exacerbating factors		What makes it worse?
R – Remitting factors		What makes it better?
S – Symptoms associated	Concurrent findings	For a cold: Fever? Chills?
M – Medications		Name, dose, frequency?
M – Medical history	Family History of disease	Previous medical diagnoses? Immunizations? Psychiatric disabilities? Genogram
A – Allergies		Food, environmental, drug – what happens?
S – Surgical history		What? When?
S – Social history	Psychosocial History	Tobacco, ETOH, drugs, education, occupation?
H - Hospitalization		What? When? Where?

Not all histories will have every component of CODIERSMMASSH. An example may be if a client complains of dizziness, you may be able to assign an imprecise intensity such as: “being so dizzy the patient fell down” or “so dizzy that the patient/client could not go to work that day”.

Other complaints may have 12 associated symptoms. An example may be someone complaining of SOB (shortness of breath). In this case you have to rule out a myocardial infarction, pneumonia, congestive heart failure, or deconditioning.

Other histories may need only a few questions, such as the patient complaining about a brown spot on the arm.

Genogram

A graphic representation of a family tree that displays detailed data on relationships among individuals. It goes beyond a traditional family tree by allowing the user to analyze hereditary patterns and psychological factors that punctuate relationships.

Genograms contain a wealth of information on the families represented. First, they contain basic data found in family trees such as the name, gender, date of birth, and date of death of each individual. Additional data may include education, occupation, major life events, chronic illnesses, social behaviors, nature of family relationships, emotional relationships, and social relationships. Some genograms also include information on disorders running in the family such as alcoholism, depression, diseases, alliances, and living situations. Genograms can vary significantly because there is no limitation as to what type of data can be included.

Review of Systems (ROS)

The Review of Systems is an inventory of symptoms related to the body’s systems. It is necessary to ask specific and directed questions for each system. The ROS is still part of the history and therefore the questions you ask and the answers your receive are not part of the physical portion of the examination.

The following table gives a brief overview of the system & symptoms for each body are.

System	Symptoms
General Survey	Fever, chills, weight loss or gain, night sweats, fatigue
Eyes	Blurred or loss of vision, double vision, eye pain, discharge, deviation
Ears, nose, mouth & throat	Ear pain, discharge, hearing loss, epistaxis, nasal congestion, lesions, tooth pain, dysphagia, tinnitus, sore throat
Cardiovascular	Palpitations, chest pain, peripheral edema, claudication, irregular heartbeats, murmur
Respiratory	SOB, orthopnea, dyspnea on exertion, coughing, wheezing, chest pain, paroxysmal nocturnal dyspnea, hemoptysis
Gastrointestinal	Dyspepsia, nausea, vomiting, diarrhea, constipation, eructation, bloating, hematemesis, hematochezia, abdominal pain, change in caliber of the stools, bright red blood per rectum, melena
Genitourinary	Hesitancy, flank pain, dysuria, hematuria, urgency, frequency, decrease in the force of stream, vaginal or penile discharge, dyspareunia, hematospermia
Musculoskeletal	Arthralgia, myalgia, boney deformity, weakness
Integumentary/breast	Changes in pigmentation or texture, rashes, lesions, pruritus, hair loss or change in hair texture, nail changes, dimpling
Neurologic	Facial asymmetry, memory loss, paresthesias, weakness, slurred speech, imbalance, changes in gait, dysphagia
Psychiatric	Depression, suicidal or homicidal ideation, anxiety, hallucinations
Endocrine	Polyuria, polyphagia, polydipsia, heat or cold intolerances
Hematologic/lymphatic	Easy bruising or bleeding, anemia, transfusion history, syncope, lymphadenopathy
Allergic/immunologic	Allergies, recurrent infections

Developmental Milestones (Peds)

Before you begin the examination, review the expected developmental milestones for the age of the patient you will be assessing. Refer to specific developmental stages to assess if your patient is meeting their tasks for their developmental age.

Objective

This section of the SOAP note includes all the information gathered through the senses – sight, hearing, smell, and touch, usually not taste. The findings from the physical examination and any laboratory or diagnostic test results go in this section.

The general format is:

Vital Signs:

General:

HEENT:

Resp:

CV/PV:

GI:

GU ( as needed)

Neuro:

MS:

MH:

Be specific within the physical exam. Note that in general the documentation follows the same sequence as the exam; ie. results of inspect, palpation, percussion, auscultation (except GI).

Common Lab Skeletons

Sodium Chloride BUN

136-146 95-110 5-20

Glucose

Potassium Bicarb Creat 70-110

3.5-5.0 21-29 0.5-1.4

Hgb

WBC 12.9-16.9 Platelets

3.8-10/6 156-369

Hct

38.0-48.8

Calcium Protein AST/SGOT LDH

8.5-10.5 6.0-8.3 10-40 100-250

T bili

Phos Albumin ALT/SGPT Alk Phos .3-1.5

2.5-4.5 3.5-5.0 10-40 40-125

Assessment

Included in this section are the diagnoses that are determined based on the subjective and objective findings. This also includes any differential diagnoses (other potential diagnoses that may be related to the presented CC.

Example: Right Temporal Arteritis with differential DX: TMJ, Migraine Headache, Cluster headache, sinusitis, meningitis, optic neuritis, carbon monoxide poisoning.

Plan

The plan should include the following:

1. Treatments

2. Medications

3. Referrals

4. Diagnostic tests to be performed

5. Education

6. Anticipatory guidance (especially for pediatric patients)

7. Recommended time for the next visit; follow-up