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Collect subjective and objective data for a focused exam problem as if they were coming to your office for an acute, focused visit. Your volunteer may role-play an acute condition for this assignment if desired.
· Conduct an interview and a physical exam based on the focused problem of your volunteer patient.
SOAP Note _______
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NU___:_________
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
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S: SUBJECTIVE DATA
CC:
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What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.
HPI:
Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
PMH:
This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Get custom essay samples and course-specific study resources via course hero homework for you service - Include dates if possible.
ALLERGIES
State the offending medication/food and the reactions.
MEDICATIONS
Names, dosages, and routes of administration along with indication of use.
SH
Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.
FH
Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known.
HEALTH PROMOTION & MAINTENANCE
Required for all SOAP notes: Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams.
ROS
(put N/A in sections not completed day of exam)
Constitutional
Head
Eyes
Ears, Nose, Mouth, Throat
Neck
Cardiovascular/Peripheral Vascular
Respiratory
Breast
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary
Neurological
Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
Other
O: OBJECTIVE DATA
VITALS:
HR:
RR:
BP:
Temp:
SpO2%:
Ht:
Wt:
BMI:
Age:
LMP:
PAIN:
PHYSICAL EXAM
(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam)
General Appearance
Head
Eyes
ENT, Mouth
Neck
Cardiovascular/Peripheral Vascular
Respiratory
Breast
Gastrointestinal
Genitourinary Male
· External Exam
· Internal Exam
Genitourinary Female
· External Exam
· Internal Exam
Musculoskeletal
Integumentary
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
Other
A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS
ICD-10 CODES
PRIORITIZE DIAGNOSIS
1.
2.
3.
VISIT CODES
CPT BILLING CODES
DIAGNOSTICS
POC TESTING
TESTS REVIEWED
P: PLAN
ACTIONS
1.
Diagnosis:
Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)
Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)
Education: information clients need in order to address their health problems. Get custom essay samples and course-specific study resources via course hero homework for you service - Include follow-up care. Anticipatory guidance and counseling.
Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.
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.
___________________________
SOAP Note
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:Focused:
S: SUBJECTIVE DATA
CC:
The patient is being seen for sudden abdominal pain.
HPI:
The patient reports that the abdominal pain started abruptly about 4 hours ago. The pain is located in the lower right quadrant of the abdomen. The patient describes the pain as sharp and intense. There are no relieving factors. The patient denies any associated symptoms such as nausea, vomiting, or fever. The patient has not taken any medication for the pain.
PMH:
No significant past illnesses or chronic conditions.
No history of traumas, hospitalizations, or surgeries.
ALLERGIES:
The patient denies any known allergies to medications or foods.
MEDICATIONS:
The patient is not currently taking any medications.
SH:
The patient has a high school education.
The patient denies smoking, alcohol, and drug use.
The patient is not sexually active.
The patient denies any caffeine intake.
The patient works as an office assistant and reports moderate work-related stress.
No cultural or spiritual beliefs impacting health and illness mentioned.
The patient has limited financial resources.
FH:
Maternal grandmother had hypertension (deceased at age 78).
Paternal grandfather had diabetes (deceased at age 72).
HEALTH PROMOTION & MAINTENANCE:
The patient is up to date with immunizations. No recent dental or eye exams.
ROS:
Constitutional: No fever, chills, or unintentional weight changes.
Head: No headache or head injury.
Eyes: No visual changes or eye pain.
Ears, Nose, Mouth, Throat: No hearing loss, nasal congestion, sore throat, or oral lesions.
Neck: No neck pain or stiffness.
Cardiovascular/Peripheral Vascular: No chest pain, palpitations, or leg swelling.
Respiratory: No shortness of breath or cough.
Breast: Not applicable (male patient).
Gastrointestinal: Abdominal pain as mentioned in CC.
Genitourinary: No urinary symptoms or changes in bowel movements.
Musculoskeletal: No joint pain or muscle weakness.
Integumentary: No skin rashes, lesions, or changes.
Neurological: No headaches, dizziness, or numbness.
Psychiatric: No symptoms of depression, anxiety, or cognitive impairment reported.
Endocrine: No symptoms of diabetes or thyroid dysfunction.
Hematologic/Lymphatic: No history of bleeding or easy bruising.
Allergic/Immunologic: No known allergies.
Other: No other relevant symptoms.
O: OBJECTIVE DATA
VITALS:
HR: 80 bpm
RR: 16 breaths per minute
BP: 120/80 mmHg
Temp: 98.6°F
SpO2%: 99%
Ht: 5 feet 10 inches
Wt: 160 lbs
BMI: 23.0 (within normal range)
Age: 32 years
LMP: Not applicable (male patient)
PAIN: The patient rates the abdominal pain as 8 out of 10 on the pain scale.
PHYSICAL EXAM:
General Appearance: The patient appears alert and oriented, in no apparent distress.
Head: Normocephalic, atraumatic.
Eyes: Pupils equal, round, and reactive to light. No conjunctival injection or scleral icterus.
ENT, Mouth: No abnormalities noted in the ears, nose, or throat.
Neck: Supple, no lymphadenopathy or jugular venous distention.
Cardiovascular/Peripheral Vascular: Regular rate and rhythm, no murm
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