unit 5 discussion

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Documentation SOAP Note

Create a focused exam SOAP note based on a case during your clinicals. This same case will be used for your Unit 6 presentation video. References should be guidelines that support the treatment plan and related condition/s.

Subjective

· Opener presentation of the patient (age/sex/presentation of issue with key past DX)

· History of present illness (HPI) (OldCarts)

· Other related past medical history

· Review of systems (ROS)

Objective

· Vital signs and physical exam on pertinent body systems

Assessment

· Assessment including differentials and specific labs or X-rays reviewed

Plan

· Explain the plan that you are suggesting or that was done, including any education, further work-up, specific medications with doses and frequency, consultations/referral, and follow-up.

Here is one of my soap notes from clinical. You can add/change as needed to make it work for the assignment please and give the references. Thanks!

I26.99 | Other pulmonary embolism without acute cor pulmonale Z71.87 | Encounter for pediatric-to-adult transition counseling

Patient Age:

45 Years

Patient Sex:

F

Patient Ethnicity:

White

Chief Complaint:

follow up s/p hospitalization

Mini-SOAP Note:

Pt presents today for follow up. She was hospitalized 3.4.24-3.5.24 for pulmonary embolism. Pt was seen here in the office by another provider in early Feb for leg pain. She had an ultrasound which showed superficial phlebitits. She was started on Naproxen. She was also seen by vascular for her varicose veins and was scheduled for another US however before she had that completed she became acutely SOB and went to the ER. Imaging in ER showed saddle PE and RLE DVT. Coag studies have been collected but are still pending. She was started on Eliquis. She had also been taking oral birth control which was discontinued. She reports her SOB has improved, especially in the last 1-2 days she is feeling much better. Her menses returned last week, as she previously had not been getting a period. She has a follow up scheduled with GYN in April. She denies CP. Denies any signs of bleeding including blood in stool, easy bruising. Notes some ongoing soreness in her right thigh. She is using heat. She has a follow up with hematology in 3 months. She is now taking Eliquis 5mg daily. VS 97.2-87-18-122/74-98% Reviewed hospital discharge summary, labs, imaging reports. Alert and oriented, normal affect. HEENT normal exam. Lungs clear, normal effort. Regular heart rate and rhythm, normal S1, S2 without murmur. No peripheral edema. +varicosities noted bilat LE. No swelling, redness. Abdominal exam benign. Plan: continue Eliquis 5mg daily. Follow up with GYN, vascular and hematology as scheduled. We discussed bleeding precautions, signs of bleeding. She had questions regarding foods to avoid which were answered. She was advised to schedule next available appointment for annual PE as she has not been seen in several years.