Draft 2

SOAPTemplate-FINAL.docx

ANP-Progress/SOAP Note Template

Reason for follow up: A one-sentence description of the primary working diagnosis that identifies admit date or hospital day of visit, pending differential diagnoses, and context or service in which the patient is being seen is provided and includes supporting details.

Clinical course summary: A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is complete with supporting documentation. (This is not the HPI.)

Review of systems: Review of the symptoms the patient or his/her family explains, organized by system. Five systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are provided with thorough details and support. Refer to the H&P template for ROS options.

Physical exam: Five systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are provided with thorough details and support. Refer to the H&P template for ROS options.

Laboratory and radiology results: List pertinent data available when seeing the patient pertinent to the reasons for follow up. Include normal and abnormal results identifying the abnormals.

Assessment: (Provide three references) Identification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are provided with thorough details and support.

· Differential diagnoses : What is pending to be ruled in or ruled out? A differential is only needed if there is a sign/symptom for which you have not identified a diagnosis.

· Acute and chronic medical conditions: Include the ICD-10 diagnosis code (look in Lopes Activity Tracker)

Treatment plan: (Provide three references) A treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is provided with thorough details and support.

What orders are you starting? What medications (include dose and frequency of new meds or changes in dose of existing meds)? What consults? Education topics? Discharge plan?

Geriatric considerations: Based on the age, please address any differences in the treatment if the patient were younger or older.

References: Use three references listed in APA format.