BM week 6 soap SOAP Note _______ NU___:_________ Herzing University

BM week 6 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

Week 6 Discussion Part I Table 1 Differential Diagnosis Pediatric Limp

Week 6 Discussion Part I Table 1 Differential Diagnosis Pediatric Limp Complete the table. CC limp Condition Age Pain (+ or -) Historical Findings Clinical Findings Causative Factors Management Developmental Dysplasia of Hip Leg-length Inequality Juvenile Arthritis Slipped capital femoral epiphysis (SCFE) Legg-Calve-Perthes disease Transient synovitis Trauma Neoplasm Septic arthritis

MENTAL STATUS EXAM GUIDE Previous Mental Health Treatments (e g: psychopharmacology, inpatient stabilization, Occupational

MENTAL STATUS EXAM GUIDE Previous Mental Health Treatments (e g: psychopharmacology, inpatient stabilization, Occupational Therapy, Vocational Therapy, Marriage/Family Therapy, Group Therapy, Detox, ECT &/or social services): What is the initial impression of the admitting examiner found in the initial evaluation, triage, or social worker note: Compare your impression of the

Comprehensive Psychiatric Evaluation Template With Psychotherapy Note Encounter date:

Comprehensive Psychiatric Evaluation Template With Psychotherapy Note Encounter date: ________________________ Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____ Reason for Seeking Health Care: ______________________________________________ HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ SI/HI: _______________________________________________________________________________ Sleep:  _________________________________________         Appetite:  ________________________ Allergies (Drug/Food/Latex/Environmental/Herbal): ___________________________________ Current perception of Health: Excellent Good Fair Poor

1

1 3 Awakening the DNP Spirit of the Scientific Underpinnings Your Name (without credentials) Miami Regional University DNP7100: Evaluation of Evidence for Practice Professor Name Month, Year Title (Introduction – not labeled ‘Introduction’) Introduce your topic of interest for practice change and its general area of either (a) clinical outcomes,

Describe causes of Upper respiratory infections and drug therapy  Discuss triggers of asthma and treatment options Discuss corticosteroids  Describe

Describe causes of Upper respiratory infections and drug therapy  Discuss triggers of asthma and treatment options Discuss corticosteroids  Describe chronic bronchitis and treatment options Describe diagnostic criteria for nausea and vomiting and treatment recommendations Discuss symptoms of GERD, complications, and drug management Compare and contrast Crohn’s disease and Ulcerative colitis