Rwh 2 soap notes

SOAP Note NU :

Herzing University

Name: Typhon Encounter #:

Comprehensive: Focused:

S: SUBJECTIVE DATA CC: The patient reported that she has been having a worse memory and forgetting

things, which is confirmed by her daughter.

HPI: History: The problems with memory started about one year ago and have become

increasingly severe.

Location: Cognitive/memory capability.

Time:Ongoing throughout the last year with slow development.

Characteristics: Becoming forgetful more often, asking the same questions and

losing things.

Related Factors: Daughter informs that patient experiences difficulties

remembering the recent conversations and appointments.

Relieving Factors: No relief is of consequence.

Treatment: No previous pharmacologic pre-visit treatment.

Summary: A 72-year-old female was admitted with progressive memory decline

during a 1-year time period that was associated with forgetfulness, repetitive

questioning, and the loss of or misplaced items.

PMH: Hypertension (was diagnosed 10 years ago), hyperlipidemia. No major surgeries

reported.

ALLERGIES NKDA

MEDICATIONS Donepezil 5 mg PO daily as a memory loss intervention.

SH Retired teacher. Lives with daughter. Denies smoking or illicit drug use.

Occasional alcohol use. No economic obstacles reported.

FH In late 70s, mother was diagnosed as having dementia. Father died when he was 80

years old because of heart attack.

HEALTH

PROMOTION &

MAINTENANCE

Patient denies severe physical exercise, walks daily. Balanced diet reported.

Vaccinations are current with influenza vaccine. Examined eyes previously last

year.

ROS

(put N/A in sections

not completed day of

exam)

Constitutional Denies fever, fatigue.

Head No headaches.

Eyes No visual changes.

Ears, Nose, Mouth, Throat No hearing loss and throat pain.

Neck No stiffness.

Cardiovascular/Peripheral

Vascular

Denies cardiac pain or palpitations.

Respiratory Denies dyspnea.

Breast

Gastrointestinal No vomit, nausea.

SOAP Note NU :

Herzing University

Name: Typhon Encounter #:

Comprehensive: Focused:

Genitourinary N/A

Musculoskeletal No joint pains.

Integumentary No rashes.

Neurological Denies forgetfulness and loss of memory.

Psychiatric (screening tools: Ex:

PHQ-9, MMSE, GAD-7)

Mild cognitive impairment observed.

Endocrine Denies being intolerant to cold or heat.

Hematologic/Lymphatic No bruising or bleeding.

Allergic/Immunologic NKDA.

Other N/A

O: OBJECTIVE DATA VITALS: HR:76 RR:16 BP:126/76 Temp: 98.4°F

SpO2%: 98% Ht: 5’4’ Wt: 150 lb BMI:25.7

Age:72 LMP: PAIN:0/10

PHYSICAL

EXAM

(Pertinent data

related to

presenting

problem or

visit type. Put

N/A in sections

not completed

day of exam)

General Appearance Observed alert, cooperative, mild impairment

of memory.

Head Normocephalic, atraumatic.

Eyes PERRLA.

ENT, Mouth Oral mucosa moist.

Neck Soft, with no lymph node.

Cardiovascular/Peripheral Vascular Normally high rate and beat.

Respiratory Clear bilaterally.

Breast

Gastrointestinal soft abdomen, non-tender.

Genitourinary Male

• External Exam N/A

• Internal Exam N/A

Genitourinary Female

• External Exam N/A

• Internal Exam N/A

Musculoskeletal the gait is normal.

Integumentary N/A

Neurological It is alert, person and place oriented and short

term memory is impaired.

Psychiatric Right mood, impaired memory slightly.

Endocrine N/A

Hematologic/Lymphatic N/A

SOAP Note NU :

Herzing University

Name: Typhon Encounter #:

Comprehensive: Focused:

Allergic/Immunologic N/A

Other N/A

A: ASSESSMENT AND DIAGNOSIS DIAGNOSIS ICD-10 CODES

PRIORITIZE DIAGNOSIS

1. Alzheimer's disease ICD-10: G30.9

2.

3.

VISIT CODES CPT BILLING CODES CPT-9: 99213

DIAGNOSTICS POC TESTING CPT-10: 99203

TESTS REVIEWED Mental examination screening (MMSE

recommended).

P: PLAN ACTIONS 1.

Diagnosis: Alzheimer's disease

Diagnostics Order:

Cognitive evaluation (MMSE), regular laboratory tests to exclude metabolic

factors.

Therapeutic:

Donepezil 5 mg PO on a daily basis, #30 tablets, 2 refills.

Education:

Management of medication adherence, routine relevance, memory aid and

caregiver assistance were discussed. Offered home safety advice such as

medication organizers and elimination of risks.

Consultation/Collaboration:

Referral to the neurology department to evaluate and manage cognition.

SOAP Note NU :

Herzing University

Name: Typhon Encounter #:

Comprehensive: Focused:

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 Repeat visit after 3 months or earlier in case of worsening of symptoms.