Assessment soap note example
Assessment soap note example
Assessment soap note example part of the SOAP NOTE
Thank you for reading this post, don't forget to subscribe!Name: | Date: | Time: |
Age: | Sex: | |
SUBJECTIVE | ||
CC:
Reason given by the patient for seeking medical care “in quotes”
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HPI:
Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
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Medications: (list with reason for med )
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PMH
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
“Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”
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Family History Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with:
lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.
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Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse,
ETOH, tobacco, marijuana. Safety status
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ROS | |
General
Weight change, fatigue, fever, chills, night sweats, energy level
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Cardiovascular
Chest pain, palpitations, PND, orthopnea, edema
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Skin
Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles
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Respiratory
Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB
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Eyes
Corrective lenses, blurring, visual changes of any kind
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Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools
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Ears
Ear pain, hearing loss, ringing in ears, discharge
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Genitourinary/Gynecological
Urgency, frequency burning, change in color of urine. Contraception, sexual activity, STDS Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx Male: prostate, PSA, urinary complaints
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Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain
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Musculoskeletal
Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis |
Breast
SBE, lumps, bumps or changes |
Neurological
Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells |
Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance |
Psychiatric
Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx |
OBJECTIVE |
Weight BMI | Temp | BP |
Height | Pulse | Resp |
General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later. | ||
Skin
Skin is brown, warm, dry, clean and intact. No rashes or lesions noted. |
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HEENT
Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair. |
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Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema. | ||
Respiratory
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. |
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Gastrointestinal
Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. |
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Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. |
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Genitourinary
Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable. (Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. ) (Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm). |
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Musculoskeletal
Full ROM seen in all 4 extremities as patient moved about the exam room. |
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Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait normal. |
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Psychiatric
Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. |
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Lab Tests
Urinalysis – pending Urine culture – pending Wet prep – pending
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Special Tests
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Diagnosis | ||
Differential Diagnoses
o 1- o 2- o 3- Diagnosis (Final) o
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Plan/Therapeutics | ||
o Plan:
▪ Further testing ▪ Medication ▪ Education ▪ Non-medication treatments
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Evaluation of patient encounter |
Name of assignment
Student Name
Course number and name
Date submitted
Instructor Name
South University, Savannah
South University Family Nurse Practitioner
Universal EPISODIC SOAP Note Template
GRADED EPISODIC SOAP NOTE SUBMISSIONS SHOULD BE COMPLETED
ON PATIENTS WITH ONE OR MORE COMPLAINTS
Revised Winter 2021
Student’s Name: Sam Student | Date: Date assignment is submitted |
Patient / Client initials: X.X | Age: XX |
Gender: Male Female Comment | Ethnicity: XXXX |
SUBJECTIVE DATA
Chief Complaint (CC) |
“My chest hurts and I feel short of breath”
In patient’s own words. Identity and reliability of informant if patient is not informant. |
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History of Present Illness (HPI)
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Onset: 2 days ago Location: sternal chest pain radiating across chest Duration: present upon awakening from sleep. Has been present daily Characteristics: dull aching pain. Sometimes it is a sharp pain Associated S/S: increased pain with upper body movement, lying down and taking a deep breath. Feels short of breath when walking but not laying down. Had a head cold about 2 weeks ago. Denies fever, chills, cough, runny nose, nasal congestion, rhinitis, nausea, chest wall trauma, and vertigo Relieving/Aggravating Factors: Tylenol 500 every 6 hours helped to decrease pain. Moist heating pad helps to decrease pain. Timing: acute onset; intermittent pain Severity: pain is 6 out of 10 and decreases to 2 out of 10. The pain is always present
FBS 115 this morning before eating. She states they have been running no higher than 140 pre-meal.
Remember to turn the above information into a narrative… 44y/o female presents with a 2 day history of substernal chest pain radiating across the chest. The pain is rated at 2/10 and is present upon waking, described as aching with episodes of sharpness dependent on positioning. Pain is worse with upper body movements, lying down and deep breathing. Associated symptom of shortness of breath with walking. No other associated symptoms reported. Has taken Tylenol 500mf every 6 hours with some relief. In addition, moist heating pad has helped to decrease pain.
For EACH component of the Chief Complaint include all elements (OLDCARTS). Include pertinent positives from the review of systems as they relate to the HPI |
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Past Medical History (PMH)
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Diabetes Mellitus, Diagnosed 2006 Hypertension, 2007 Hyperlipidemia, 2008 GERD, 2021 Influenza B, 2010 Depression (situational r/t death of father, 2012) Tobacco abuse, started smoking 20 years ago Acute appendicitis, age 18 Acute cholecystitis, 2010 Colon Cancer, 2014
In chronological order: Current/Past medical problems with date of onset |
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Past Surgical History (PSH) |
Appendectomy, age 18 Cholecystectomy, 2010 Exploratory lap, 2015 for abdominal pain, normal findings Hospitalized for small bowel resection, colon cancer 2014 Liposuction of abdomen, May 2019
In chronological order: Surgeries and Procedures with date performed and outcome |
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OB/GYN history (if applicable) |
Gravida 2 Para 2, A 0 LMP: 10 years ago, menopausal Last PAP: March 2019, normal findings Last Mammogram: Marsh 2019, normal findings Hx of STD: negative history of STD
Gravida/Para. Last menstrual period. Last PAP w/ results. Last Mammogram w/ results. History of STD |
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Immunization status |
Childhood immunizations completed include smallpox, diphtheria, tetanus, pertussis, polio (OPV), measles, mumps, rubella Active case of chicken pox, age 8 TdaP, 2017 Pneumovax, 2018 Influenza vaccine contraindicated due to egg allergy
Age specific immunizations, list and describe any history of reactions |
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Medications |
Lisinopril 20mg 1 tablet by mouth once a day for essential HTN Atorvastatin 20mg 1 tablet by mouth at bedtime for hyperlipidemia Tylenol Extra Strength, 2 tablets by mouth every 6 hours as needed for pain Pepcid 20mg 1 tablet by mouth twice a day as needed for GERD
Current medications: include medication name, dose, route, frequency, duration, and reason for taking |
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Allergies |
Allergy to eggs – rash, childhood Allergy to ACE inhibitors – angioedema, 2010 Not allergic to environment or latex
Medications, Foods, Environmental, Latex and how allergy is manifested |
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Family History (FH) |
Paternal GF: deceased age 78 from car accident, CAD, CABG, DM2 Paternal GM: deceased age 50 from AMI, breast CA Maternal GF: living age 85, prostate CA under hospice care Maternal GM: deceased age 84 natural causes, hypothyroidism Father: living age 68, DM2, Essential HTN, CVA Mother: living age 64, essential HTN Brother: living, age 42, essential HTN Sister: living, age 38, healthy without chronic disease Daughter (adopted): living age 10, healthy without chronic disease
Blood relatives: Age, living/deceased, medical problems, Include grandparents, parents, siblings, and children |
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Psychosocial or Social History (SH) |
Divorced heterosexual female who is not currently in a sexual relationship 1 child – daughter who was adopted at birth Denies use of illegal or recreational drugs Drinks 1-2 beers every weekend for at least 20 years Does not exercise regularly Eats fast food meals at least 1-2 times per day Cigarette smoker for 20 years, 1 pack per day. Not interested in cessation MSN prepared registered nurse and works as FNP in primary care office Southern Baptist who does not attend church regularly due to work schedule Stressors include being single parent with young daughter
Pt. profile (sexual orientation, marital status, children), Lifestyle risk factors (illicit drug use, smoking/pack year, exercise) , Employment history, Education, Religion – beliefs, Cultural history, Support System, Stressors, Driving |
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Nutritional Screening when applicable |
Screened using Nestle’s Nutritional Screening Tool Score is 1 of 10 which indicates adequate nutritional status Area of deficiency was only eating 2 meals per day (skips breakfast)
Report findings from a nutritional screening tool you used to interview patient |
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Advanced Directives |
Has a written Advanced Directive with DPOAHC. There is not a copy on the chart She wants her mother to make medical decisions if incapacitated Wants to have CPR and be placed on ventilator should cardiopulmonary arrest occur
Report patient wishes and initials of decision-maker/relationship of DPOAHC |
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Episodic visits should include ROS and Physical Exam only for body systems relevant to the complaint
Review your differential diagnosis list and be sure to include all body systems which will adequately evaluate the differential diagnosis |
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Review of Systems(ROS) | ||
Do not repeat your HPI information in the ROS or physical examination sections.
Typically, only negatives are reported in the ROS.section. Positives should be reported in the HPI.
Episodic SOAP note should have 3-5 elements addressed in the pertinent body system Comprehensive SOAP note should have 5-8 elements addressed in the pertinent body system |
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Constitutional |
General statement by the patient (reported symptoms that do not fit one system but often affect overall status) |
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Skin |
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Eyes, Ears, Nose Throat/Mouth |
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Cardiovascular |
Denies radiation of chest pain into jaws or arms, palpitations, racing heart, |
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Respiratory |
Negative for hemoptysis, wheezing, productive cough, exposure to TB |
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Gastrointestinal |
Denies abdominal pain, nausea, vomiting, heartburn, waterbrash. Chest pain does not occur in relation to meals.
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Reproductive / Genitalia / Genitourinary |
Not needed for this concern (chest pain) |
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Musculoskeletal |
Denies muscle weakness, neck or shoulder pain, and tremors |
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Neurological |
Denies numbness, tingling, loss of movement or sensation, vertigo |
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Psychiatric |
Denies anxiety, depression, suicidal or homicidal thoughts |
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Endocrine |
Denies increased thirst, hunger, unexplained weight loss or gain, |
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Hematologic /Lymphatic |
Denies hemoptysis, swollen nodes, and fever |
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Immune function |
Denies recurrent infections, use of immunosuppressants, and low blood cell counts |
OBJECTIVE DATA
Physical Exam
Avoid describing findings as “normal”, “WNL”, “appropriate”, “intact”. Instead describe what you found on evaluation Episodic SOAP note should have 3-5 elements addressed in the pertinent body system Comprehensive SOAP note should have 5-8 elements addressed in the pertinent body system |
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Constitutional |
XX year old XXX female in no acute distress. Speech clear and appropriately answers questions. Good historian.
General description of patient including age, gender, nutritional status, habitus, attention to grooming, state of cooperativeness/demeanor, overall picture of wellness/distress |
Vital Signs |
Bp 135/74. Pulse 82. Respirations 20 Temp 98.7 orally.Pulse ox on room air is 97% Height 66 inches. Weight 227 lbs. BMI 36.6
Temperature, Pulses (apical and radial), Respirations, BP (Postural PRN), Ht, Wt, BMI |
Skin |
Skin pink with rebound less than 2 seconds. Capillary refill brisk in fingers bilaterally.Herpetic rash absent to chest, torso, abdomen, and flank. |
HEENT |
Eyes: PERRLA. Ears: TM’s pearly gray bilaterally without effusion. Light reflex @5 on right and @7 on left Nose: Nares patent bilaterally. Turbinates pale without exudate or polyps. Throat: Pharynx without redness or irritation. Dentition does not show erosions |
Neck |
Negative lymph node swelling at anterior and posterior cervical chains as well as infra and supraclavicular areas. |
Respiratory |
Chest is tender to palpation along 2nd to 5th costochondral joints at the sternum bilaterally. The pain is reproducible with deep breath and when patients rotates chest. Breath sounds are clear bilaterally and cough is not productive. Chest is symmetrical with bilateral chest rise. Chest percussion negative for consolidation. |
Cardiovascular |
Regular S1 and S2 without gallop or murmur. PMI located midclavicular line at 5th ICS. Radial and pedal pulses are 2+ bilaterally. Negative homan’s sign bilaterally. Peripheral edema absent bilateral lower extremities |
Breast |
Not needed |
Abdomen |
Abdomen soft, non-tender throughout. Positive bowel sounds x4 quadrants. Liver and spleen not palpable. Negative rebound on light and deep palpation. |
Female Genitourinary/
GYN if applicable |
Not needed
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Male Genitourinary/
Prostate if applicable |
Not needed |
Rectal |
Not needed |
Musculoskeletal
Including frailty evaluation if applicable |
Non-tender to palpation at cervical spine, bilateral clavicles, and shoulders. Neck and shoulders with full active ROM. Gait steady without imbalance |
Neurological |
Alert, oriented to name, place, and date. Deep tendon reflexes 2+ at radialis and Achilles.
(Mental Status, Cranial nerves, Motor, Cerebellum, Motor, Cerebellum, Sensory, Reflexes) |
Psychiatric |
Mood is pleasant. Demonstrates insight as evidenced by verbalization that uncontrolled hypertension can cause her kidneys to fail. Demonstrates judgement as evidenced by compliance with taking medications.
(Minimal documentation is mood, insight, and judgement. Document findings from depression screen, Mini-mental status exam, CAGE, etc.) |
Diagnostic Information |
2.10.19 EKG negative for ischemia, injury, and infarct 2.2.18 Cholesterol was 250
Results of diagnostic testing conducted at the time of the visit OR previously done and being used to support the diagnosis and management plan for the current visit |
ASSESSMENT: DIFFERENTIAL DIAGNOSES AND SUPPORTING DATA
5 differential diagnoses
for each presenting problem |
Data in your findings that support this diagnosis | Data in your findings that rule out this diagnosis | Citation of evidence for accepting or rejecting the diagnosis |
Costochondritis |
HPI / ROS:
sternal chest pain radiating across chest, pain is reproducible with inspiration, recent respiratory infection Pain waxes and wanes Meds: Pain improves with NSAID
SH: smokes 1 pack per day
PE: Chest pain diminishes when holding breath Costal areas tender to touch, pain is reproducible with movement CXR: negative for pneumonia, CHF EKG: negative AMI |
HPI/ ROS:
Presence of shortness of breath, absence of chest wall trauma,
PE: Blood pressure is normal 135/74. Lungs are clear , chest percussion negative for consolidation |
Accepting Diagnosis because
Patient has costal tenderness which is 98% sensitive for inflammation as cause of pain (Blue et al, 2018) |
Acute Myocardial infarction |
HPI / ROS:
sternal chest pain radiating across chest, shortness of breath
PMH: personal history of HTN,
FH: family history of CAD, CVA,
SH: smokes 1 pack per day, does not exercise, eats fast foods daily
PE: negative for … Positive for …. Dx: cholesterol on Feb 2, 2018 was 250 |
HPI/ ROS:
Did not have diaphoresis, pain improves with NSAID
PMH: BMI indicates healthy weight, negative for CAD, AMI
PE: Blood pressure is normal 135/74. tenderness across the anterior chest at costovertebral angles bilaterally, pain is reproducible with inspiration
Dx: EKG negative for injury (ST changes), ischemia (change in T-wave), and infarct (Q wave changes) |
Rejecting Diagnosis because:
Pain of angina and AMI typically is not reproducible nor does it improve with the use of NSAID. EKG negative for findings of ischemia, injury, infarct. (Smith et al, 2018) |
GERD | HPI / ROS:
sternal chest pain radiating across chest, gets worse when laying down
PMH: personal history of GERD
Meds: Pepcid help to decrease chest pain
SH: smokes 1 pack per day, does not exercise, eats fast foods daily
PE: negative for … Positive for …. |
HPI/ ROS:
Absence of heart burn, waterbrash, pain is not related to food intake, pain decreases with NSAID
PMH: BMI indicates healthy weight,
PE: Blood pressure is normal 135/74. Pharynx without redness or irritation, dentition does not show erosion, abdomen soft, non-tender, positive bowel sounds |
Rejecting Diagnosis because:
Absence of heartburn and waterbrash along with pain not related to food intake makes the likelihood of GERD diagnosis less than 10% according to Jones et al, 2018 |
Pneumonia | HPI / ROS:
sternal chest pain radiating across chest, shortness of breath, pain is reproducible with inspiration, recent respiratory infection
SH: smokes 1 pack per day, does not exercise, eats fast foods daily
PE:
Negative for …
Positive for …. |
HPI/ ROS: Does not have fever, tachycardia, chills, malaise
PMH: no history of immunosuppression
PE: Blood pressure is normal 135/74. Lungs are clear , chest percussion negative for consolidation Dx: EKG without is |
Rejecting:
Patient is not demonstrating S/S of acute infection including fever and chills and physical exam of lungs does not reveal congestion or consolidation. (Blue et al, 2018) |
Pulmonary Emboli | HPI / ROS:
sternal chest pain radiating across chest, shortness of breath,
PMH: recent liposuction of abdomen last month
SH: smokes 1 pack per day, does not exercise, eats fast foods daily
PE: Negative for … Positive for …. |
HPI/ ROS:
Pain decreases with NSAID use, does not have hemoptysis
PMH: negative for coagulopathy
FH: negative for coagulopathy
SH: negative risk factors for clotting event – recent travel, use of OCP
PE: Blood pressure is normal 135/74. Lungs are clear , negative peripheral edema and homan’s sign bilaterally
Dx: D-Dimer normal |
Absence of risk factors for thrombosis, along with negative d-dimer decreases the likelihood of pulmonary emboli to less than 3%. Pain of pulmonary emboli also does not respond to NSAID use
(Peter & Paul, 2016) |
Final ICD 10 diagnosis codes for the current visit
ICD 10 Code | Corresponding Diagnosis |
1.
M94 |
Acute costochondritis
Primary diagnosis for the visit |
2.
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3.
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4. | |
5. |
Additional diagnoses for the visit AND active problems from the medical history that may contribute to the diagnosis and plan for the current visit (ie DMII or HTN may impact management even if the visit is not related to these diagnoses) |
PLAN: TREATMENT PLAN
(For graded SOAP note submissions, include rationale for all components of treatment plan and support with citations from peer-reviewed information)
Additional Diagnostic tests needed |
Chest x-ray completed today in the office but will have to await radiology interpretation which takes 24 hours. Chest x-ray is recommended for patients suspected of having costochondritis who are older than 35 years and/or have signs and symptoms of a coronary event (Author, Year)
include rationale with citation for each diagnostic test being ordered |
Treatments: Pharmacological |
Celebrex 200mg 1 tablet by mouth twice a day. NSAIDS work to decrease inflammation of the costochondral area (Author,year)
Tylenol Extra Strength 2 tablets by mouth every 6 hours as needed for pain. Research shows Tylenol is effective for relief of mild to moderate pain (Author, year)
If there is not improvement in pain within 24-48 hours, will consider Medrol dose pak as stronger anti-inflammatory may be needed (Author,year)
Precipitating event is likely a viral URI and patient is no longer symptomatic. Therefore anti-infectives are not indicated (Author, year)
include rationale with citation for each pharmacological treatment ordered |
Treatments: Non-Pharmacological |
Continue to apply local heat for 10 minutes every 1-2 hours as needed to discomfort. Heat increases blood flow and makes connective tissue more flexible which will decrease joint pain and reduce inflammation (Author, year)
Avoid unnecessary exercise or activities that make the symptoms worse such as reaching up, twisting the torso, or lifting objects. Limited activity will allow inflammation to resolve (Author, year)
Return to normal activities when they are tolerated. As inflammation decreases, normal day to day activities are less painful and should be resumed to avoid stiffness and loss of motion (Author, year)
include rationale with citation for each non-pharmacological treatment ordered |
Patient Education |
Provided handout on costochondritis including symptoms and treatment plan outlined above. Educated patient on the side effects and adverse effects of Celebrex and Tylenol.
Rationale: Empowering patients with knowledge on how to manage and improve their own health helps to engage the patient in self-care and encourages them to take responsibility for their health (Author, date)
nclude rationale with citation for patient education |
Consultations recommended with Rationale |
Referral to cardiology – Dr. Yam Lam – to continue evaluation of chest pain associated with shortness of breath. Appointment is Tuesday June 30, 2019 at 11:15 am.
include rationale with citation for each consultation ordered. Also include the name of the provider, area of specialty, and date/time of the appointment |
Disposition |
Return to office in 5 days for follow-up to evaluate patient progress and effectiveness of medications (Author, year)
Next office visit scheduled, identify the plan for follow-up, note expectations for further treatment. |
CPT Billing Codes Reflected in the Treatment Plan
CPT Code | Corresponding Diagnosis |
1. 99213
Office visit E/M code |
Established office visit, expanded problem focused history, exam, and low complexity medical decision-making |
2. 85004 | Complete Blood Count |
3. 93040
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EKG |
4. 71010 | Chest X-ray, single view frontal |
5.
Point of care testing (urine dipstick, wet mount, x rays, etc.) and resulted IN OFFICE, and any procedures done in office |
IM. A. FNP Student
South University Savannah GA
Patient Name ______________X.X________________ Date ___Month/Date/Year_________ |
Rx
Celebrex 200mg capsules Sig: one capsule by mouth twice a day Disp: #30
No refills.
Refills: __0__
Signature ______Sallie Student, RN, NP Student________________________ |
References
JOURNAL ARTICLES
Author, A. (Year). Title of journal article. Title of Journal, volume (issue if paginated),
page ranges. doi:
Author A. (Year). Title of journal article. Title of Journal, volume, page ranges.
doi:
Author, A. (Year). Title of journal article. Title of Journal, volume, pages ranges.
Retrieved from URL for home page of journal.
BOOKS: ELECTRONIC
Author, A. (Year). Title of book (edition). E-book vendor. Retrieved from URL
address.
Author, A. & Author, B. (Year). Title of chapter in a book. In C. Author & D. Author (Eds.),
Title of Book (x edition). Retrieved form URL for digital book.
BOOKS: UP-TO-DATE (electronic edited book format)
Author, A., & Author, B. (Year). Title of article in the book. In X. Y. Author (Ed.), UpToDate.
Retrieved from https://www.uptodate.com/contents/topic
BOOKS: PRINT
Author, A., & Author, B. (Year). Title of chapter in a book. In C. Author & D. Author (Eds.),
Title of Book (x edition)(pages – pages). City, State published: Name of publisher.0
Author, A., & Author, B., (Year). Title of book (edition). City of Publication: Publisher.
ENCYCLOPEDIA
Topic. (Year). In Name of Encyclopedia or Dictionary. City of Publication: Publisher.
Topic. (Year). In Name of Encyclopedia or Dictionary. Retrieved from….
WEBSITE: PAGE OR ARTICLE
Author, A. (Year, Month Day). Title of web page. Website. Retrieved from URL address
WEBSITE: ENTIRE SITE
Author, A. (Year, Month, Day). Title of Website. Retrieved from URL address.
Author, A. (Year). Name of chapter. In X.X. XYZ (ed.), UpToDate. Retrieved from URL address.
WEBSITE: No AUTHOR
Title of webpage. (Year, Month, Day). Retrieved from URL address.
GRADING RUBIC FOR EPISODIC SOAP NOTES
SUBJECTIVE FINDINGS: | Chief compliant, HPI | 10 |
The patient’s explanation of what the problem is, in the form of a summarized narration. | Allergies, Meds, PMH, Surgical Hx, Social Hx, Family Hx, and any relevant hx | 10 |
ROS: Select the elements that are most pertinent to the patient’s concerns, yet meet clinical standards for best practice & diagnostic accuracy. Remember to address the appropriate # of organ systems for the level of the service billed | 10 | |
OBJECTIVE FINDINGS:
Includes the info that’s collected from the pt’s current health situation. Includes: ht, wt, vs & physical findings |
Focused PE. You will only examine the systems that are pertinent to the CC, HPI and history. DO NOT use WNL or normal. You MUST describe what you see.
-Include results of point of care testing conducted at the time of the visit OR diagnostic testing previously done and being used to support the diagnosis & management plan for the current visit |
25 |
ASSESSMENT
This is a summary of the key symptoms & diagnosis of the pt. and a list of other likely diagnoses. |
Include 3 differential and a final diagnosis. Make sure you identify how you ruled in/out a diagnosis using current evidence-based references within the past 5 years.
-Use correct ICD10 codes for final diagnosis. -Final diagnosis may include any active medical problems being addressed in the patient education & treatment plan |
20 |
PLAN
Steps that the provider will take to treat the patient and their concerns |
Identify diagnostics, prescriptions, referrals, patient education, patient disposition, follow up appointment.
-Use CPT billing codes for office visit (Level of service) and for testing conducted during the office visit. Again, make sure you identify the rationale for your patient education and/or treatment plans using current evidence-based references within the past 5 years. |
20 |
APA Format | Use of correct APA 7th ed format including title page, reference page, correct grammar/spelling and proper citations | 5 |
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