Nursing SOAP NOTE Homework

Patient Demographics

Age:

90+ years

Biological Sex:

Female

Race:

White, Non Hispanic

Insurance:

Medicaid

Referral:

No referral

Clinical Information

Time with Patient:

20 minutes

Consult with Preceptor:

Type of Decision-Making:

Low complexity

Student Participation:

Less than shared

Reason for Visit:

Episodic

Chief Complaint:

physical

Encounter #:

1

Type of HP:

Problem Focused

Social Problems Addressed:

Procedures/Skills (Observed/Assisted/Done)  (Critical in Bold)

ICD-10 Diagnosis Codes

#1 - Z00.00 - ENCNTR FOR GENERAL ADULT MEDICAL EXAM W/O ABNORMAL FINDINGS #2 - Z76.0 - ENCOUNTER FOR ISSUE OF REPEAT PRESCRIPTION #3 - Z68.1 - BODY MASS INDEX (BMI) 19.9 OR LESS, ADULT

CPT Billing Codes

#1 - 99213 - OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; LOW LEVEL MED DECISION; 20-29 MIN

Medications

# OTC Drugs taken regularly:

0

# Prescriptions currently prescribed:

0

# New/Refilled Prescriptions This Visit:

0

Types of New/Refilled Prescriptions This Visit:

Adherence Issues with Medications:

Other Questions About This Case

Patient choice of language:

English

Patient is unable verbalize / speak:

Patient is verbal and cooperative:

Patient does not speak English:

Patient comatose / unresponsive:

Patient is ambulatory:

Maintains NP-patient relationship :

Participates in NP role :

Manages health care deliverysystems:

Proves culturally competent care:

Incorporates NP role into care:

Indirect :

Clinical Notes

Sex: FeMale

DOB: 11/11/1928

Age: 94 Yrs

CHIEF COMPLAINT:PHYSICAL W.L

HISTORY OF PRESENT ILLNESS:Pleasant 94 year old female presents with daughter for a followup appointment and medication refill. Patient has no complaints or concerns for today's visit. States she lives alone, but near family (daughters). Patient states she walks daily using cane and right hip is feeling strong following hip surgery that took place one year ago. Denies recent illness and states her appetite is very good. She states she is compliant with her medications, Norvasc and ASA, and they are working well for her. Patient states she notices bilateral peripheral edema at the end of the day, but she elevates legs and sees improvement. She uses a walker and cane for ambulation.

MEDICAL HISTORY:Common: Essential Hypertension

SOCIAL HISTORY:

· Alcohol: Denies alcohol use

· Illicit Drugs: Caffeine usage 1 cup /day

· Smoking: Does not actively smoke tobacco and has never smoked

· Marital Status: She is widowed

· Working Status: She is currently unemployed

ACTIVE MEDICATIONS: Medication Reviewed/

Reconciled

Amlodipine Besylate 10mg Tablets   Take 1 Tablet By Mouth Every Day

Aspirin 81MG Tablet Chewable 1 Po  Q D

Norvasc 10MG Tablet 1 Po  Q D

ALLERGIES:

· No Known Drug Allergies.

· No Known Food Allergies.

· No Known Environmental Allergies.

VITALS:

Weight: 107 lbs / 48.53 kg

Height: 5.4 ft BMI: 18.4BSA: 1.5

BP: 140/70

Pulse Rate: 86

BPMResp. Rate: 16 RPM

Temp: 97.5 F

Pain Scale: 0

ROS:Refer to HPI. The patient was also asked about all other systems. All other systems were reviewed and are negative

PHYSICAL EXAM:

Gen: Pt. is alert, oriented to place, person and time, NAD

HEENT: Normocephalic, extraocular movements intact, pupils equal and reactive to light, normal moist mucosa of nose and throat.

Chest: CTAB, no wheezes, rales and rhonchi

CVS: RRR, s1/s2

Abd: positive for BS, soft, NT/ND

Ext: no pedal edema, cyanosis/clubbing.

Neuro: II-XII cranial nerves intact, moving all four extremities, FROM, sensory/ motor intact

ASSESSMENT

1. Z76.0-Encounter For Issue Of Repeat Prescription

2. Z00.0 encounter for  normal physical exam

3. Body mass index (BMI) 19 or less, adult(Z68.1)

Differentials- 3. Normal or high BMI, 1. prescription reaction or need to increase dose (both BP meds BP stable),  2. murmur, enlarged thyroid, adventitious breath sounds (negative assessment none of these finding found) pt declined screenings. PLAN:

Z76.0-Encounter For Issue Of Repeat Prescription

Erx to designated pharmacy.

3. I10-Essential (primary) Hypertension

· Continue medication

· Keep track of the BP readings.

· Cut down coffee intake

· continue the low salt diet and exercise on a daily basis.

· Pt. advised to avoid stress.

· call us if the SBP is more than 150.

PRESCRIPTION ORDERS:Amlodipine Besylate 10MGTAKE 1 TABLET BY MOUTH EVERY DAY1 Refills # 90(Ninety),Norvasc 10MG1 po Q d1 Refills # 90(Ninety)

Body Mass Index: 18.4- eat plenty of healthy foods to maintian caloric intake

Weight: 107

Height: 64Fall Risk Screening 65 Years And Older:How many times in the past year did you fall: 0 or one fall

Confirm Patient has walker/cane or other ambulatory assistance: No

How often does it happen to you that you think you are about to fall, but manage to grab something and then don’t fall: Never or rarely have near falls

 Follow up can include visit with PCP, Specialist or Physical Therapy.: Yes 

Patient Demographics

Age:

90+ years

Biological Sex:

Female

Race:

White, Non Hispanic

Insurance:

Medicaid

Referral:

No referral

Clinical Information

Time with Patient:

20 minutes

Consult with Preceptor:

Type of Decision-Making:

Low complexity

Student Participation:

Less than shared

Reason for Visit:

Episodic

Chief Complaint:

physical

Encounter #:

1

Type of HP:

Problem Focused

Social Problems Addressed:

Procedures/Skills (Observed/Assisted/Done)  (Critical in Bold)

ICD-10 Diagnosis Codes

#1 - Z00.00 - ENCNTR FOR GENERAL ADULT MEDICAL EXAM W/O ABNORMAL FINDINGS #2 - Z76.0 - ENCOUNTER FOR ISSUE OF REPEAT PRESCRIPTION #3 - Z68.1 - BODY MASS INDEX (BMI) 19.9 OR LESS, ADULT

CPT Billing Codes

#1 - 99213 - OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; LOW LEVEL MED DECISION; 20-29 MIN

Medications

# OTC Drugs taken regularly:

0

# Prescriptions currently prescribed:

0

# New/Refilled Prescriptions This Visit:

0

Types of New/Refilled Prescriptions This Visit:

Adherence Issues with Medications:

Other Questions About This Case

Patient choice of language:

English

Patient is unable verbalize / speak:

Patient is verbal and cooperative:

Patient does not speak English:

Patient comatose / unresponsive:

Patient is ambulatory:

Maintains NP-patient relationship :

Participates in NP role :

Manages health care deliverysystems:

Proves culturally competent care:

Incorporates NP role into care:

Indirect :

Clinical Notes

Sex: FeMale

DOB: 11/11/1928

Age: 94 Yrs

CHIEF COMPLAINT:PHYSICAL W.L

HISTORY OF PRESENT ILLNESS:Pleasant 94 year old female presents with daughter for a followup appointment and medication refill. Patient has no complaints or concerns for today's visit. States she lives alone, but near family (daughters). Patient states she walks daily using cane and right hip is feeling strong following hip surgery that took place one year ago. Denies recent illness and states her appetite is very good. She states she is compliant with her medications, Norvasc and ASA, and they are working well for her. Patient states she notices bilateral peripheral edema at the end of the day, but she elevates legs and sees improvement. She uses a walker and cane for ambulation.

MEDICAL HISTORY:Common: Essential Hypertension

SOCIAL HISTORY:

· Alcohol: Denies alcohol use

· Illicit Drugs: Caffeine usage 1 cup /day

· Smoking: Does not actively smoke tobacco and has never smoked

· Marital Status: She is widowed

· Working Status: She is currently unemployed

ACTIVE MEDICATIONS: Medication Reviewed/

Reconciled

Amlodipine Besylate 10mg Tablets   Take 1 Tablet By Mouth Every Day

Aspirin 81MG Tablet Chewable 1 Po  Q D

Norvasc 10MG Tablet 1 Po  Q D

ALLERGIES:

· No Known Drug Allergies.

· No Known Food Allergies.

· No Known Environmental Allergies.

VITALS:

Weight: 107 lbs / 48.53 kg

Height: 5.4 ft BMI: 18.4BSA: 1.5

BP: 140/70

Pulse Rate: 86

BPMResp. Rate: 16 RPM

Temp: 97.5 F

Pain Scale: 0

ROS:Refer to HPI. The patient was also asked about all other systems. All other systems were reviewed and are negative

PHYSICAL EXAM:

Gen: Pt. is alert, oriented to place, person and time, NAD

HEENT: Normocephalic, extraocular movements intact, pupils equal and reactive to light, normal moist mucosa of nose and throat.

Chest: CTAB, no wheezes, rales and rhonchi

CVS: RRR, s1/s2

Abd: positive for BS, soft, NT/ND

Ext: no pedal edema, cyanosis/clubbing.

Neuro: II-XII cranial nerves intact, moving all four extremities, FROM, sensory/ motor intact

ASSESSMENT

1. Z76.0-Encounter For Issue Of Repeat Prescription

2. Z00.0 encounter for  normal physical exam

3. Body mass index (BMI) 19 or less, adult(Z68.1)

Differentials- 3. Normal or high BMI, 1. prescription reaction or need to increase dose (both BP meds BP stable),  2. murmur, enlarged thyroid, adventitious breath sounds (negative assessment none of these finding found) pt declined screenings. PLAN:

Z76.0-Encounter For Issue Of Repeat Prescription

Erx to designated pharmacy.

3. I10-Essential (primary) Hypertension

· Continue medication

· Keep track of the BP readings.

· Cut down coffee intake

· continue the low salt diet and exercise on a daily basis.

· Pt. advised to avoid stress.

· call us if the SBP is more than 150.

PRESCRIPTION ORDERS:Amlodipine Besylate 10MGTAKE 1 TABLET BY MOUTH EVERY DAY1 Refills # 90(Ninety),Norvasc 10MG1 po Q d1 Refills # 90(Ninety)

Body Mass Index: 18.4- eat plenty of healthy foods to maintian caloric intake

Weight: 107

Height: 64Fall Risk Screening 65 Years And Older:How many times in the past year did you fall: 0 or one fall

Confirm Patient has walker/cane or other ambulatory assistance: No

How often does it happen to you that you think you are about to fall, but manage to grab something and then don’t fall: Never or rarely have near falls

 Follow up can include visit with PCP, Specialist or Physical Therapy.: Yes