Mitz week 4 soapSOAP Note _______ NU___:_________ Herzing University

Mitz week 4 soap

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

  Therapeutic RelationshipCase

  Therapeutic Relationship Case  Cases J.J is a nurse practitioner who works in a primary care facility. He believes that one of the most important aspects of his work is to foster a therapeutic relationship with his clients. He is using effective communication techniques. Many of his clients have altered

15 S 21st St., Suite 205 Fargo, ND 58103

15 S 21st St., Suite 205 Fargo, ND 58103     BASIC ASSURANCES SYSTEM     Procedure Title: Basic Assurances System  Procedure Type: Service Operations  Number: 10 Original Date Issued: 03/11/2022  Effective Date: 03/11/2022  Approved By: Gibson W. Jerue, CEO  Approved Date: 03/11/2022  Revision Date(s):   Policy Reference: Basic Assurances System    Disability