4 soaps needed RW

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SOAP Note Assignment Instructions

Consider constructing a Word document ‘SOAP note template’ and use it to assemble your note. By doing this you can use the template for efficiently constructing your SOAP notes such that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty person requests to see your SOAP note template you will be required to send it to them for review.

Sections of the SOAP note should be addressed if they are pertinent to the presenting chief complaint.

Typhon Encounter #:

Type of Note: Focused or Comprehensive

Subjective (S):

CC: chief complaint - What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.

HPI: Who is the historian? Is the historian reliable? History of Present Illness - use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]

Past medical history (PMH) - This should include illness/diagnosis, conditions, traumas, hospitalizations, and surgical history that is pertinent to the visit. Include dates if possible.

Reproductive history: GTPAL, STIs, prenatal care, LMP, contraceptive methods, sexual and menstrual history. Include dates if possible.

Allergies: State the offending medication/food and the reactions.

Medications: Names, dosages, routes, frequency, and indications. Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work, and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.

Family history: Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known.

Health Maintenance/Promotion - Required for all SOAP notes: Immunizations, exercise, diet, screening, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age-appropriate indicators, Healthy People 2030, and Centers for Disease Control and Prevention (CDC). This should reflect patient’s current recommendations. Up to date on health maintenance/promotion will NOT be accepted. Requires references.

Review of systems (ROS) –

• [Refer to your course modules and the Bickley E-text (Bates Guide) as a guide when conducting your ROS to make sure you have not missed any important symptoms,

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particularly in areas that you have not already thoroughly explored while discussing the history of present illness.]

You would also want to include any pertinent negatives or positives that would help with your differential diagnosis. For acute episodic or follow-up visits (focused note) you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc. As opposed to a comprehensive visit which would address each system.

Perform either a focused or comprehensive ROS based on the visit type.

General: May include if patient has had a fever, chills, fatigue, malaise, etc.

Skin:

HEENT: head, eyes, ears, nose, and throat

Neck:

Breast:

CV: cardiovascular

Resp: respiratory

GI: gastrointestinal

GYN: gynecologic

GU: genito-urinary

PV: peripheral vascular

MSK: musculoskeletal

Neuro: neurological

Endo: endocrine

Psych:

Objective (O):

Physical exam (PE) – • [Refer to your course modules and the Bickley E-text (Bates Guide) as a guide when

determining what physical assessments, you want to include to further explore what you have learned from your subjective data collection]

Perform either a focused or comprehensive exam based on the visit type.

This area should confirm your findings related to the diagnosis. For acute episodic or follow-up visits (focused) you may be omitting certain areas such as GYN, Rectal, Abd, etc. While a comprehensive visit will exam each area.

Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the

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same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory. Gen: general statement of appearance if there is any acute distress.

VS: vital signs, height and weight, BMI

Skin:

HEENT: head, eyes, ears, nose, and throat

Neck:

Breast:

CV: cardiovascular

Resp: respiratory

GI: gastrointestinal

GU: genito-urinary

Gyn: gynecologic

PV: peripheral vascular

MSK: musculoskeletal

Neuro: neurological

Endo: endocrine

Psych:

Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).

Assessment (A): This section should be a write-up utilizing your clinical decision-making with your diagnosis/diagnoses being supported by your ‘S’ data set and the ‘O’ data set. Pertinent positives and negatives must be found in the write-up. References required.

Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.

Remember to include the appropriate ICD-10 code for each diagnosis.

A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e., HTN-well managed on medication).

Plan (P):

Your plan should be supported by evidence-based guidelines with appropriate citations utilizing APA formatting. Your evidence-based plan may be deviated from your preceptor’s plan. Be sure to comment if there is a deviation in standard of care.

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Document individual plans directly after each corresponding assessment (i.e., Diagnosis #1 found in the assessment should correlate with Plan #1). Address the following aspects (it should be separated out as listed below):

Diagnostics: labs, diagnostics testing - tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint. Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including the name of the medication, dose, route, quantity, and number of refills for any new or refilled medications.

Educational: information clients need in order to address their health problems including the diagnosis itself, education on diagnostics, and therapies. Include follow-up care. Anticipatory guidance and counseling.

Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.

CPT: References Reference should support your patient’s management plan, including evidence-based practice, and utilize APA formatting.

SOAP Note _______ NU___:_________

Herzing University

Name:_________________________ Typhon Encounter #: _____________________

Comprehensive:____Focused:____

S: SUBJECTIVE DATA CC: What are they being seen for? This is the reason that the patient sought

care, stated in their own words/words of their caregiver, or paraphrased.

HPI: Use the “OLDCART” approach for collecting data and documenting

findings. [O=onset, L=location, D=duration, C=characteristics,

A=associated/aggravating factors, R=relieving factors, T=treatment,

S=summary]

PMH: This should include past illness/diagnosis, conditions, traumas,

hospitalizations, and surgical history. Include dates if possible.

ALLERGIES State the offending medication/food and the reactions.

MEDICATIONS Names, dosages, and routes of administration along with indication of

use.

SH Related to the problem, educational level/literacy, smoking, alcohol,

drugs, HIV risk, sexually active, caffeine, work and other stressors.

Cultural and spiritual beliefs that impact health and illness. Financial

resources.

FH Use terms like maternal, paternal, and the diseases along with the ages

they were deceased or diagnosed if known.

HEALTH

PROMOTION &

MAINTENANCE

Required for all SOAP notes: Immunizations, exercise, diet, etc.

Remember to use the United States Clinical Preventative Services Task

Force (USPSTF) for age-appropriate indicators. This should reflect what

the patient is presently doing regarding the guidelines. Other wellness

visits including but not limited to dental and eye exams.

ROS

(put N/A in sections

not completed day of

exam)

Constitutional

Head

Eyes

Ears, Nose, Mouth, Throat Neck Cardiovascular/Peripheral

Vascular

Respiratory

Breast

Gastrointestinal

SOAP Note _______ NU___:_________

Herzing University

Name:_________________________ Typhon Encounter #: _____________________

Comprehensive:____Focused:____

Genitourinary Musculoskeletal

Integumentary

Neurological

Psychiatric (screening tools: Ex:

PHQ-9, MMSE, GAD-7)

Endocrine

Hematologic/Lymphatic Allergic/Immunologic

Other

O: OBJECTIVE DATA VITALS: HR: RR: BP: Temp:

SpO2%: Ht: Wt: BMI:

Age: LMP: PAIN:

PHYSICAL

EXAM

(Pertinent data

related to

presenting

problem or

visit type. Put

N/A in sections

not completed

day of exam)

General Appearance

Head

Eyes

ENT, Mouth Neck Cardiovascular/Peripheral Vascular

Respiratory

Breast

Gastrointestinal Genitourinary Male

• External Exam

• Internal Exam

Genitourinary Female

• External Exam

• Internal Exam

Musculoskeletal

Integumentary

Neurological

Psychiatric

Endocrine

Hematologic/Lymphatic

SOAP Note _______ NU___:_________

Herzing University

Name:_________________________ Typhon Encounter #: _____________________

Comprehensive:____Focused:____

Allergic/Immunologic

Other

A: ASSESSMENT AND DIAGNOSIS DIAGNOSIS ICD-10 CODES

PRIORITIZE DIAGNOSIS

1.

2.

3.

VISIT CODES CPT BILLING CODES

DIAGNOSTICS

POC TESTING

TESTS REVIEWED

P: PLAN ACTIONS 1. Diagnosis:

Diagnostics Order: labs, diagnostics testing (tests that you planned

for/ordered during the encounter that you plan to review/evaluate

relative to your work up for the patient’s chief complaint.)

Therapeutic: changes in meds, skin care, counseling, include full

prescribing information for any pharmacologic interventions

including quantity and number of refills for any new or refilled

medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no

refills)

Education: information clients need in order to address their health

problems. Include follow-up care. Anticipatory guidance and

counseling.

SOAP Note _______ NU___:_________

Herzing University

Name:_________________________ Typhon Encounter #: _____________________

Comprehensive:____Focused:____

Consultation/Collaboration: referrals or consult while in clinic with

another provider. If no referral made was there a possible referral

you could make and why? Advance care planning.

2. Diagnosis:

Diagnostics Order:

Therapeutic:

Education:

Consultation/Collaboration:

3. Diagnosis:

Diagnostics Order:

Therapeutic:

Education:

Consultation/Collaboration:

PREVENTITIVE

(Used for

comprehensive exams)

Enter Guidance, Health Promotion, and/or Disease Prevention for

patient, family, and/or caregiver.

FOLLOW UP