Roch week 6 soap
SOAPNoteTemplate-Final281293.docx 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 Read More …