Assessment soap note example

Assessment soap note example

Assessment soap note example part of the SOAP NOTE

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Name: Date: Time:
Age: Sex:
SUBJECTIVE
CC: 

Reason given by the patient for seeking medical care “in quotes”

 

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.

 

Medications: (list with reason for med )

 

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.”

 

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.

 

Social History

Education level, occupational history, current living situation/partner/marital status, substance use/abuse,

 

ETOH, tobacco, marijuana.  Safety status

 

 

 

ROS
General

Weight change, fatigue, fever, chills, night sweats,  energy level

 

Cardiovascular

Chest pain, palpitations, PND, orthopnea, edema

 

Skin

Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles

 

Respiratory

Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB

 

Eyes

Corrective lenses, blurring, visual changes of any kind

 

Gastrointestinal

Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools

 

Ears

Ear pain, hearing loss, ringing in ears, discharge

 

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

 

Nose/Mouth/Throat

Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain

 

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.

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.

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.

Gastrointestinal

Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.

Breast

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.

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).

Musculoskeletal

 

Full ROM seen in all 4 extremities as patient moved about the exam room.

Neurological

 

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

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.

Lab Tests

Urinalysis – pending

Urine culture – pending

Wet prep – pending

 

Special Tests

 

 

 

 

 

 

 Diagnosis
 Differential Diagnoses

o    1- o    2- o    3-

Diagnosis (Final)

o

 

Plan/Therapeutics
                        o    Plan:

▪  Further testing

▪  Medication

▪  Education

▪  Non-medication treatments

 

 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.

 

History of Present Illness (HPI)

 

 

Onset2 days ago

Location:   sternal chest pain radiating across chest

Durationpresent upon awakening from sleep.  Has been present daily

Characteristicsdull aching pain.  Sometimes it is a sharp pain

Associated S/Sincreased 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 FactorsTylenol 500 every 6 hours helped to decrease pain.  Moist heating pad helps to decrease pain.

Timingacute onset; intermittent pain

Severitypain 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

 

Past Medical History (PMH)

 

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

 

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

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

 

 

Constitutional

 

 

 

General statement by the patient (reported symptoms that do not fit one system but often affect overall status)

 

Skin

 

 

 

Eyes, Ears, Nose Throat/Mouth  

 

 

Cardiovascular

 

Denies radiation of chest pain into jaws or arms, palpitations, racing heart,

 

Respiratory

 

Negative for hemoptysis, wheezing, productive cough, exposure to TB

 

Gastrointestinal

 

Denies abdominal pain, nausea, vomiting, heartburn, waterbrash.  Chest pain does not occur in relation to meals.

 

Reproductive / Genitalia / Genitourinary  

Not needed for this concern (chest pain)

 

Musculoskeletal

 

Denies muscle weakness, neck or shoulder pain, and tremors

 

Neurological

 

Denies numbness, tingling, loss of movement or sensation, vertigo

 

Psychiatric

 

Denies anxiety, depression, suicidal or homicidal thoughts

 

Endocrine

 

Denies increased thirst, hunger, unexplained weight loss or gain,

 

Hematologic /Lymphatic

 

Denies hemoptysis, swollen nodes, and fever

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

 

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

 

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.

 

3.

 

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
199213

 

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

 

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.

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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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You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.
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