MR case study week 6

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

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

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

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.

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

Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver.

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