SOAP Note _______ NU___:_________ Herzing University | Name:_________________________ Typhon Encounter #: _____________________ Comprehensive:____Focused:____ |
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 |
| |
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 |
VITALS: | HR: | RR: | BP: | Temp: |
SpO2%: | Ht: | Wt: | BMI: | |
Age: | LMP: | PAIN: | ||
(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 | ||
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: | |
(Used for comprehensive exams) | Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver. | |
FOLLOW UP |