soap may 12Identify a friend, peer, or family member you can SOAP Note _______

soap may 12

  • Identify a friend, peer, or family member you can 

SOAP Note _______

NU___:_________

Herzing University

Name:_________________________

Typhon Encounter #: _____________________

Comprehensive:____Focused:____


S: SUBJECTIVE DATA

CC:

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. 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. 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.

FOLLOW UP

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

As a psychiatric mental health nurse practitioner (PMHNP), how do you approach the management of treatment-resistant schizophrenia, particularly in

As a psychiatric mental health nurse practitioner (PMHNP), how do you approach the management of treatment-resistant schizophrenia, particularly in cases where traditional antipsychotic medications and psychosocial interventions have been ineffective? What are the challenges and opportunities in utilizing biomarkers of inflammation to aid in the early diagnosis and personalized treatment

Module 6 Discussion  PersonhoodDiscuss the concept of

Module 6 Discussion   Personhood Discuss the concept of personhood as used in the nursing as caring theory. Submission Instructions: · Your initial post must be at least 500 words, formatted, and cited in current APA style with support from at least two academic sources. · Quotes “……” cannot be

Module 6 Discussion  Treatments for  Genitourinary Tract Disorders

Module 6 Discussion   Treatments for  Genitourinary Tract Disorders Based on  Module 6: Lecture Materials & Resources and experience, please answer the following questions: 1. Describe urinary tract infection, causes, symptoms and treatment 2. Discuss treatment for benign prostatic hyperplasia 3. Describe overactive bladder, causes, symptoms and treatment  4. Treatment options