Episodic/Focused SOAP Note Template
Affected person Info:
Initials, Age, Intercourse, Race
S.
CC (chief grievance) a BRIEF assertion figuring out why the affected person is right here – within the affected person’s personal phrases – for example “headache”, NOT “dangerous headache for three days”.
HPI: That is the symptom Assessment part of your be aware. Thorough documentation on this part is crucial for affected person care, coding, and billing Assessment. Paint an image of what’s mistaken with the affected person. Use LOCATES Mnemonic to finish your HPI. You want to begin EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). It’s essential to embody the seven attributes of every principal symptom in paragraph kind not an inventory. If the CC was “headache”, the LOCATES for the HPI would possibly appear to be the next instance:
Location: head
Onset: three days in the past
Character: pounding, stress across the eyes and temples
Related indicators and signs: nausea, vomiting, photophobia, phonophobia
Timing: after being on the pc all day at work
Exacerbating/ relieving components: gentle bothers eyes, Aleve makes it tolerable however not utterly higher
Severity: 7/10 ache scale
Present Medicines: embody dosage, frequency, size of time used and purpose to be used; additionally embody OTC or homeopathic merchandise.
Allergic reactions: embody remedy, meals, and environmental allergy symptoms individually (an outline of what the allergy is ie angioedema, anaphylaxis, and many others. This may Help decide a real response vs intolerance).
PMHx: embody immunization standing (be aware date of final tetanus for all adults), previous main sicknesses and surgical procedures. Relying on the CC, extra information is typically wanted
Soc Hx: embody occupation and main hobbies, household standing, tobacco & alcohol use (earlier and present use), another pertinent knowledge. At all times add some well being promo Question Assignment right here – akin to whether or not they use seat belts on a regular basis or whether or not they have working smoke detectors in the home, residing setting, textual content/mobile phone use whereas driving, and Help system.
Fam Hx: sicknesses with attainable genetic predisposition, contagious or continual sicknesses. Cause for dying of any deceased first diploma kinfolk must be included. Embrace mother and father, grandparents, siblings, and youngsters. Embrace grandchildren if pertinent.
ROS: cowl all physique techniques that will allow you to embody or rule out a differential analysis You need to listing every system as follows: Basic: Head: EENT: and many others. You need to listing these in bullet format and doc the techniques so as from head to toe.
Instance of Full ROS:
GENERAL: Denies weight reduction, fever, chills, weak spot or fatigue.
HEENT: Eyes: Denies visible loss, blurred imaginative and prescient, double imaginative and prescient or yellow sclerae. Ears, Nostril, Throat: Denies listening to loss, sneezing, congestion, runny nostril or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest ache, chest stress or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No belly ache or blood.
GENITOURINARY: Burning on urination. Being pregnant. Final menstrual interval, MM/DD/YYYY.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling within the extremities. No change in bowel or bladder management.
MUSCULOSKELETAL: Denies muscle, again ache, joint ache or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No historical past of splenectomy.
PSYCHIATRIC: Denies historical past of despair or nervousness.
ENDOCRINOLOGIC: Denies stories of sweating, chilly or warmth intolerance. No polyuria or polydipsia.
ALLERGIES: Denies historical past of bronchial asthma, hives, eczema or rhinitis.
O.
Bodily examination: From head-to-toe, embody what you see, hear, and really feel when doing all of your bodily examination. You solely want to look at the techniques which might be pertinent to the CC, HPI, and Historical past. Don’t use “WNL” or “regular.” It’s essential to describe what you see. At all times doc in head to toe format i.e. Basic: Head: EENT: and many others.
Diagnostic outcomes: Embrace any labs, x-rays, or different diagnostics which might be wanted to develop the differential diagnoses (Help with evidenced and pointers)
A.
Differential Diagnoses (listing a minimal of three differential diagnoses).Your main or presumptive analysis must be on the high of the listing. For every analysis, present supportive documentation with proof based mostly pointers.
P.
This part will not be required for the assignments on this course (NURS 6512) however can be required for future programs.
References
You might be required to incorporate no less than three proof based mostly peer-reviewed journal articles or evidenced based mostly pointers which pertains to this case to Help your diagnostics and differentials diagnoses. You’ll want to use appropriate APA seventh version formatting.
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SOAP Note Template (Episodic/Focused)
Info for Sufferers:
Initials, Age, Gender, and Race
S.
CC (chief grievance) is a SHORT assertion that identifies why the affected person is right here – within the affected person’s personal phrases – for instance, “headache,” NOT “extreme headache for three days.”
HPI: That is your be aware’s symptom Assessment part. This part’s documentation is essential for affected person care, coding, and billing Assessment. Create a psychological picture of what’s mistaken with the affected person. To complete your HPI, use the LOCATES Mnemonic. Each HPI ought to start with age, race, and gender (e.g., 34-year-old AA male). It’s essential to point out the seven traits of every main symptom in paragraph fashion, not an inventory. If the CC was “headache,” the LOCATES for the HPI could appear to be this:
