Bb week 6 soap
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SOAP Note _______ NU___:_________ Herzing University |
Name:_________________________ Typhon Encounter #: _____________________ Comprehensive:____Focused:____ |
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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. |
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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] |
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PMH: |
This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. |
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ALLERGIES |
State the offending medication/food and the reactions. |
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MEDICATIONS |
Names, dosages, and routes of administration along with indication of use. |
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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. |
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FH |
Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known. |
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HEALTH PROMOTION & MAINTENANCE |
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ROS (put N/A in sections not completed day of exam) |
Constitutional |
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Head |
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Eyes |
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Ears, Nose, Mouth, Throat |
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Neck |
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Cardiovascular/Peripheral Vascular |
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Respiratory |
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Breast |
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Gastrointestinal |
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Genitourinary |
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Musculoskeletal |
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Integumentary |
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Neurological |
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Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) |
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Endocrine |
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Hematologic/Lymphatic |
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Allergic/Immunologic |
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Other |
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VITALS: |
HR: |
RR: |
BP: |
Temp: |
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SpO2%: |
Ht: |
Wt: |
BMI: |
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Age: |
LMP: |
PAIN: |
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(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam) |
General Appearance |
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Head |
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Eyes |
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ENT, Mouth |
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Neck |
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Cardiovascular/Peripheral Vascular |
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Respiratory |
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Breast |
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Gastrointestinal |
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Genitourinary Male |
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· External Exam |
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· Internal Exam |
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Genitourinary Female |
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· External Exam |
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· Internal Exam |
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Musculoskeletal |
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Integumentary |
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Neurological |
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Psychiatric |
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Endocrine |
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Hematologic/Lymphatic |
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Allergic/Immunologic |
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Other |
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A: ASSESSMENT AND DIAGNOSIS |
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DIAGNOSIS |
ICD-10 CODES |
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PRIORITIZE DIAGNOSIS |
1. |
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2. |
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3. |
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VISIT CODES |
CPT BILLING CODES |
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DIAGNOSTICS |
POC TESTING |
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TESTS REVIEWED |
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P: PLAN |
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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. |
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2. |
Diagnosis: Diagnostics Order: Therapeutic: Education: Consultation/Collaboration: |
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3. |
Diagnosis: Diagnostics Order: Therapeutic: Education: Consultation/Collaboration: |
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(Used for comprehensive exams) |
Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver. |
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FOLLOW UP |
