Collect subjective and objective data for a focused exam problem

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.

· Conduct an interview and a physical exam based on the focused problem of your volunteer patient.
SOAP Note _______

NU___:_________

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.

___________________________
SOAP Note

NU___:_________

Herzing University

Name:_________________________

Typhon Encounter #: _____________________

Comprehensive:Focused:

S: SUBJECTIVE DATA

CC:
The patient is being seen for sudden abdominal pain.

HPI:
The 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.

PMH:

No significant past illnesses or chronic conditions.
No history of traumas, hospitalizations, or surgeries.
ALLERGIES:
The patient denies any known allergies to medications or foods.

MEDICATIONS:
The patient is not currently taking any medications.

SH:

The patient has a high school education.
The patient denies smoking, alcohol, and drug use.
The patient is not sexually active.
The patient denies any caffeine intake.
The patient works as an office assistant and reports moderate work-related stress.
No cultural or spiritual beliefs impacting health and illness mentioned.
The patient has limited financial resources.
FH:

Maternal grandmother had hypertension (deceased at age 78).
Paternal grandfather had diabetes (deceased at age 72).
HEALTH PROMOTION & MAINTENANCE:
The patient is up to date with immunizations. No recent dental or eye exams.

ROS:
Constitutional: No fever, chills, or unintentional weight changes.
Head: No headache or head injury.
Eyes: No visual changes or eye pain.
Ears, Nose, Mouth, Throat: No hearing loss, nasal congestion, sore throat, or oral lesions.
Neck: No neck pain or stiffness.
Cardiovascular/Peripheral Vascular: No chest pain, palpitations, or leg swelling.
Respiratory: No shortness of breath or cough.
Breast: Not applicable (male patient).
Gastrointestinal: Abdominal pain as mentioned in CC.
Genitourinary: No urinary symptoms or changes in bowel movements.
Musculoskeletal: No joint pain or muscle weakness.
Integumentary: No skin rashes, lesions, or changes.
Neurological: No headaches, dizziness, or numbness.
Psychiatric: No symptoms of depression, anxiety, or cognitive impairment reported.
Endocrine: No symptoms of diabetes or thyroid dysfunction.
Hematologic/Lymphatic: No history of bleeding or easy bruising.
Allergic/Immunologic: No known allergies.
Other: No other relevant symptoms.

O: OBJECTIVE DATA

VITALS:
HR: 80 bpm
RR: 16 breaths per minute
BP: 120/80 mmHg
Temp: 98.6°F
SpO2%: 99%
Ht: 5 feet 10 inches
Wt: 160 lbs
BMI: 23.0 (within normal range)
Age: 32 years
LMP: Not applicable (male patient)
PAIN: The patient rates the abdominal pain as 8 out of 10 on the pain scale.

PHYSICAL EXAM:

General Appearance: The patient appears alert and oriented, in no apparent distress.

Head: Normocephalic, atraumatic.

Eyes: Pupils equal, round, and reactive to light. No conjunctival injection or scleral icterus.

ENT, Mouth: No abnormalities noted in the ears, nose, or throat.

Neck: Supple, no lymphadenopathy or jugular venous distention.

Cardiovascular/Peripheral Vascular: Regular rate and rhythm, no murm