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.<\/p>\n
\u00b7 Conduct an interview and a physical exam based on the focused problem of your volunteer patient.
\nSOAP Note _______<\/p>\n
NU___:_________<\/p>\n
Name:_________________________<\/p>\n
Typhon Encounter #: _____________________<\/p>\n
Comprehensive:____Focused:____<\/p>\n
S: SUBJECTIVE DATA<\/p>\n
CC:<\/p>\n
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.<\/p>\n
HPI:<\/p>\n
Use the \u201cOLDCART\u201d 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]<\/p>\n
PMH:<\/p>\n
This should include past illness\/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.<\/p>\n
ALLERGIES<\/p>\n
State the offending medication\/food and the reactions.<\/p>\n
MEDICATIONS<\/p>\n
Names, dosages, and routes of administration along with indication of use.<\/p>\n
SH<\/p>\n
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.<\/p>\n
FH<\/p>\n
Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known.<\/p>\n
HEALTH PROMOTION & MAINTENANCE<\/p>\n
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.<\/p>\n
ROS<\/p>\n
(put N\/A in sections not completed day of exam)<\/p>\n
Constitutional<\/p>\n
Head<\/p>\n
Eyes<\/p>\n
Ears, Nose, Mouth, Throat<\/p>\n
Neck<\/p>\n
Cardiovascular\/Peripheral Vascular<\/p>\n
Respiratory<\/p>\n
Breast<\/p>\n
Gastrointestinal<\/p>\n
Genitourinary<\/p>\n
Musculoskeletal<\/p>\n
Integumentary<\/p>\n
Neurological<\/p>\n
Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)<\/p>\n
Endocrine<\/p>\n
Hematologic\/Lymphatic<\/p>\n
Allergic\/Immunologic<\/p>\n
Other<\/p>\n
O: OBJECTIVE DATA<\/p>\n
VITALS:<\/p>\n
HR:<\/p>\n
RR:<\/p>\n
BP:<\/p>\n
Temp:<\/p>\n
SpO2%:<\/p>\n
Ht:<\/p>\n
Wt:<\/p>\n
BMI:<\/p>\n
Age:<\/p>\n
LMP:<\/p>\n
PAIN:<\/p>\n
PHYSICAL EXAM<\/p>\n
(Pertinent data related to presenting problem or visit type. Put N\/A in sections not completed day of exam)<\/p>\n
General Appearance<\/p>\n
Head<\/p>\n
Eyes<\/p>\n
ENT, Mouth<\/p>\n
Neck<\/p>\n
Cardiovascular\/Peripheral Vascular<\/p>\n
Respiratory<\/p>\n
Breast<\/p>\n
Gastrointestinal<\/p>\n
Genitourinary Male<\/p>\n
\u00b7 External Exam<\/p>\n
\u00b7 Internal Exam<\/p>\n
Genitourinary Female<\/p>\n
\u00b7 External Exam<\/p>\n
\u00b7 Internal Exam<\/p>\n
Musculoskeletal<\/p>\n
Integumentary<\/p>\n
Neurological<\/p>\n
Psychiatric<\/p>\n
Endocrine<\/p>\n
Hematologic\/Lymphatic<\/p>\n
Allergic\/Immunologic<\/p>\n
Other<\/p>\n
A: ASSESSMENT AND DIAGNOSIS<\/p>\n
DIAGNOSIS<\/p>\n
ICD-10 CODES<\/p>\n
PRIORITIZE DIAGNOSIS<\/p>\n
1.<\/p>\n
2.<\/p>\n
3.<\/p>\n
VISIT CODES<\/p>\n
CPT BILLING CODES<\/p>\n
DIAGNOSTICS<\/p>\n
POC TESTING<\/p>\n
TESTS REVIEWED<\/p>\n
P: PLAN<\/p>\n
ACTIONS<\/p>\n
1.<\/p>\n
Diagnosis:<\/p>\n
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\u2019s chief complaint.)<\/p>\n
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)<\/p>\n
Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.<\/p>\n
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.<\/p>\n
2.<\/p>\n
Diagnosis:<\/p>\n
Diagnostics Order:<\/p>\n
Therapeutic:<\/p>\n
Education:<\/p>\n
Consultation\/Collaboration:<\/p>\n
3.<\/p>\n
Diagnosis:<\/p>\n
Diagnostics Order:<\/p>\n
Therapeutic:<\/p>\n
Education:<\/p>\n
Consultation\/Collaboration:<\/p>\n
PREVENTITIVE<\/p>\n
(Used for comprehensive exams)<\/p>\n
Enter Guidance, Health Promotion, and\/or Disease Prevention for patient, family, and\/or caregiver.<\/p>\n
___________________________
\nSOAP Note<\/p>\n
NU___:_________<\/p>\n
Herzing University<\/p>\n
Name:_________________________<\/p>\n
Typhon Encounter #: _____________________<\/p>\n
Comprehensive:Focused:<\/p>\n
S: SUBJECTIVE DATA<\/p>\n
CC:
\nThe patient is being seen for sudden abdominal pain.<\/p>\n
HPI:
\nThe 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.<\/p>\n
PMH:<\/p>\n
No significant past illnesses or chronic conditions.
\nNo history of traumas, hospitalizations, or surgeries.
\nALLERGIES:
\nThe patient denies any known allergies to medications or foods.<\/p>\n
MEDICATIONS:
\nThe patient is not currently taking any medications.<\/p>\n
SH:<\/p>\n
The patient has a high school education.
\nThe patient denies smoking, alcohol, and drug use.
\nThe patient is not sexually active.
\nThe patient denies any caffeine intake.
\nThe patient works as an office assistant and reports moderate work-related stress.
\nNo cultural or spiritual beliefs impacting health and illness mentioned.
\nThe patient has limited financial resources.
\nFH:<\/p>\n
Maternal grandmother had hypertension (deceased at age 78).
\nPaternal grandfather had diabetes (deceased at age 72).
\nHEALTH PROMOTION & MAINTENANCE:
\nThe patient is up to date with immunizations. No recent dental or eye exams.<\/p>\n
ROS:
\nConstitutional: No fever, chills, or unintentional weight changes.
\nHead: No headache or head injury.
\nEyes: No visual changes or eye pain.
\nEars, Nose, Mouth, Throat: No hearing loss, nasal congestion, sore throat, or oral lesions.
\nNeck: No neck pain or stiffness.
\nCardiovascular\/Peripheral Vascular: No chest pain, palpitations, or leg swelling.
\nRespiratory: No shortness of breath or cough.
\nBreast: Not applicable (male patient).
\nGastrointestinal: Abdominal pain as mentioned in CC.
\nGenitourinary: No urinary symptoms or changes in bowel movements.
\nMusculoskeletal: No joint pain or muscle weakness.
\nIntegumentary: No skin rashes, lesions, or changes.
\nNeurological: No headaches, dizziness, or numbness.
\nPsychiatric: No symptoms of depression, anxiety, or cognitive impairment reported.
\nEndocrine: No symptoms of diabetes or thyroid dysfunction.
\nHematologic\/Lymphatic: No history of bleeding or easy bruising.
\nAllergic\/Immunologic: No known allergies.
\nOther: No other relevant symptoms.<\/p>\n
O: OBJECTIVE DATA<\/p>\n
VITALS:
\nHR: 80 bpm
\nRR: 16 breaths per minute
\nBP: 120\/80 mmHg
\nTemp: 98.6\u00b0F
\nSpO2%: 99%
\nHt: 5 feet 10 inches
\nWt: 160 lbs
\nBMI: 23.0 (within normal range)
\nAge: 32 years
\nLMP: Not applicable (male patient)
\nPAIN: The patient rates the abdominal pain as 8 out of 10 on the pain scale.<\/p>\n
PHYSICAL EXAM:<\/p>\n
General Appearance: The patient appears alert and oriented, in no apparent distress.<\/p>\n
Head: Normocephalic, atraumatic.<\/p>\n
Eyes: Pupils equal, round, and reactive to light. No conjunctival injection or scleral icterus.<\/p>\n
ENT, Mouth: No abnormalities noted in the ears, nose, or throat.<\/p>\n
Neck: Supple, no lymphadenopathy or jugular venous distention.<\/p>\n
Cardiovascular\/Peripheral Vascular: Regular rate and rhythm, no murm<\/p>\n","protected":false},"excerpt":{"rendered":"
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