In Week 3, you completed a focused SOAP note. This week, you will complete a comprehensive SOAP note. Both types of SOAP note provide a cognitive framework for diagnostic reasoning and treatment planning.
To prepare:
Review the Comprehensive SOAP Note Template.
Select a patient who you saw at your practicum site during the last 5 weeks. With this patient in mind, consider the following:
Subjective: What details did the patient provide regarding the personal and medical history?
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient Assessment?
(M1021) Primary Diagnosis Code:
E11.9
03
(M1021) Primary Diagnosis
Type 2 diabetes mellitus without
complications
Severity:
(M1023) Other Diagnosis Code:
I10
03
(M1023) Other Diagnosis
Essential (primary) hypertension
Severity:
(M1023) Other Diagnosis Code:
E87.1
02
(M1023) Other Diagnosis
Hypo-osmolality and hyponatremia
Severity:
(M1023) Other Diagnosis Code:
N39.0
02
(M1023) Other Diagnosis
Urinary tract infection, site not specified
Severity:
(M1023) Other Diagnosis Code:
R11.2
02
(M1023) Other Diagnosis
Nausea with vomiting, unspecified
Severity:
(M1023) Other Diagnosis Code:
F32.A
02
(M1023) Other Diagnosis
Depression, unspecified
Severity:
(M1023) Other Diagnosis Code:
M54.59
02
(M1023) Other Diagnosis
Other low back pain
Severity:
(M1023) Other Diagnosis Code:
E78.5
02
(M1023) Other Diagnosis
Hyperlipidemia, unspecified
Severity:
(M1023) Other Diagnosis Code:
G90.09
02
(M1023) Other Diagnosis
Other idiopathic peripheral autonomic
neuropathy
1 – Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
✓
✓
2 – Diabetes Mellitus (DM)
3 – None of the above
Patient is a 82 years old hispanic
female presented due to health/medical condition being unstable
and genarlized weakness, and recent discharge from hospital after a acute episode of UTI. Patient
requires partial Help with transfer.
Patient with multiple DX: DM II,
HTN, Depression, chronic low back pain, and other comorbidities.
Patient for Admission to HHCS based upon medical necessity and homebound status and based on the
assessment of the patient’s rehabilitation potential, that D/T multiple and complex medical condition that could deteriorate at anytime, the condition of the patient will
improve with continued skilled SN teachings/Management/monitoring for optimal outcomes / goal attainment, and or the services are necessary to the establishment of a
safe and effective maintenance program, and to prevent and exacerbation. Live with daughter. Referral to home care Apex SN , HHA, PT services for strengthen . UTI cleared at this time
1. LISINOPRIL 20 MG ORAL TABLET
1 tab twice a day By mouth (PO) New cardiovascular agents
2. 12/19/2022 GABAPENTIN 300 MG ORAL CAPSULE
2 cap twice a day By mouth (PO) New anticonvulsants
3. 12/19/2022 SODIUM CHLORIDE 1 mg
1 tab day QHS By mouth (PO) New nutritional products
4. 12/19/2022 PREDNISONE4MG ORAL TABLET
1 tab x 5 days By mouth (PO) New glucocorticoids
5. 12/19/2022 CARVEDILOL 25 MG ORAL TABLET
1 tab twice a day By mouth (PO) New cardiovascular agents
6. 12/19/2022 METFORMIN 500 MG ORAL TABLET
2 tab twice a day By mouth (PO) New antidiabetic agents
7. 12/19/2022 HYDROXYZINE HYDROCHLORIDE 25 MG ORAL TABLET
1 tab as need By mouth (PO) New central nervous system agents
8. 12/19/2022 SIMVASTATIN 40 MG ORAL TABLET
1 tab day By mouth (PO) New antihyperlipidemic agents
9. 12/19/2022 novolog 70/30 flex pen
30 units AM subcutaneous (SQ) New insulin
10. 12/19/2022 novolog 70/30 flex pen
20 units PM subcutaneous (SQ) New insulin
11. 11/17/2022 Tylenol 8HRS ARTHRITIS 650MG
1-2TABS EVERY 6HRS AS NEEDED FOR PAIN By mouth (PO)
Heart Rate: Greater Than(>) 90 Less Than (<) 60
Temp: Greater Than (>) 100 Less Than (<) 95 Respirations: Greater Than (>) 24 Less Than (<) 12 Pain Level: Greater Than (>) 7 O2
Saturation: Less Than (<) 95 Systolic BP: Greater Than (>) 160 Less Than (<) 60
Diastolic BP: Greater Than (>) 90 Less Than (<) 60 Blood Sugar, Fasting: Greater Than (>) 200 Less Than (<) 60 Blood Sugar, Random:
Greater Than (>) 300 Less Than (<) 60
—
Subjective: The patient is a 82 year old Hispanic female who presented to the clinic with generalized weakness and an unstable health condition. She recently had an acute episode of a urinary tract infection and was discharged from the hospital. The patient requires partial Helpance with transfers and lives with her daughter.
Objective: During the physical assessment, the patient was alert and oriented with clear speech. She had dry mucous membranes and a regular pulse and respiratory rate. The patient had stable vital signs and no distress. She had a history of Type 2 diabetes mellitus, hypertension, depression, chronic low back pain, and other comorbidities. The patient’s lower extremities had poor perfusion and she had multiple wounds on her feet. The patient also had a history of peripheral vascular disease or peripheral arterial disease.
Assessment: Based on the patient’s presentation and medical history, the following are the differential diagnoses, listed from highest priority to lowest priority:
Peripheral vascular disease or peripheral arterial disease (CPT code: 93922, ICD-10 code: I70.2)
Diabetes mellitus (CPT code: 250.00, ICD-10 code: E11.9)
None of the above (CPT code: N/A, ICD-10 code: N/A)
The primary diagnosis is Peripheral vascular disease or peripheral arterial disease due to the patient’s history of poor perfusion in her lower extremities and the presence of wounds on her feet.
Plan: The plan for diagnostics for the primary diagnosis includes referral for a vascular study and wound care management. The plan for treatment and management includes pharmacologic and non-pharmacologic interventions, such as aspirin and wound care dressings, as well as referral for physical therapy and home health care services to improve the patient’s strength and mobility. The patient will also receive education on how to manage her diabetes and hypertension, as well as follow-up with her primary care physician.
Reflection notes: My “aha” moment during this patient Assessment was when I realized the potential impact of the patient’s comorbidities on her overall health and well-being. In a similar situation, I would be sure to thoroughly assess and address all of the patient’s medical conditions in order to provide the most comprehensive care possible.
