Tonia is an 18-year-old female who presents to your office complaining of two months of amenorrhea. Her pregnancy test is positive and her LMP indicates she is 5.6 weeks EGA. She reports she has had some bleeding for the past 3 days, that started as spotting but has continued to be a light period- like bleeding today. She denies any pain. She indicates plans to continue the pregnancy.
Please include questions and patients answer
1. Subjective:
a. What other relevant questions should you ask regarding the HPI?
b. What other medical history questions should you ask?
c. What other social history questions should you ask?
2. Objective:
a. Describe all elements of the head-to-toe assessment you will perform for her initial prenatal visit
b. Explain what test(s) you will order and perform and discuss your rationale for ordering and performing each test.
3. Assessment/ Diagnosis:
a. What are your presumptive and differential diagnoses, and why?
b. Any other diagnosis or differential diagnosis you would like to add?
c. Assume you ordered an HCG today and the result was 1200. She returns to the clinic in 2 days and her HCG results is 550. What would be her diagnosis?
4. Plan:
a. How will you explain the HCG results to your patient?
b. Explain treatment guidelines and side effects including any possible side effects of the medication and treatment(s), partner notification, and follow-up plan of care.
c. What patient education is important to include for this patient? (Consider when can the patient resume sexual activity, birth control options, when she can resume trying to conceive again).
Provide evidence from the research to support your decision-making.
Complete a SOAP note assessment after answering all the questions. Please explain your diagnosis and explain why you choose that diagnosis
Here is a sample format of the DB SOAP note.
Subjective
CC:
HPI:
Medications:
Allergies:
LMP:
Gyn/OB history:
PMH:
Chronic Illness/ Major trauma:
Family Hx:
Social Hx:
ROS
– List the body systems and provide answers
– (Don’t forget to include Gyn ROS)
– You can include questions here that you’d like to ask the patient
Objective Data
General- provide findings
VS
List body systems- provide findings
– (Don’t forget Gyn System)
– (You can include answers here to questions posed in the prompt)
Include POCT (Point of Care testing) not labs that you will send to the laboratory
Assessment/ Diagnosis
Include the ICD10 code
DDX
Plan
Diagnostic tests Lab Tests
Treatment
Medication
Referrals
Education
Health Maintenance
Follow up
Soap note example make surge to include GYN system
Demographic Data
· Patient age and gender identity
· MUST BE HIPAA compliant
Subjective
Chief Complaint (CC)
· Place the complaint in Quotes
· Brief description -only a few words and in the patient’s words
· Example: “My chest hurts,” “I cannot breath,” or “I passed out,” etc.
History of Present Illness (HPI) – the reason for the appointment today
· Use the OLDCARTS acronym to document the eight elements of a chief concern (CC): Onset, Location/radiation, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity
· Briefly describe the general state of health prior to the problem.
Past Medical History:
· List current and past medical diagnoses (in list format)
Past Surgical History:
· List all past surgeries including dates (in list format)
FAMILY HISTORY:
· Include medical/psychiatric problems to include 2 generations (parents, grandparents, siblings, or direct relatives (in list format).
Current Medications:
· Include current prescription(s), over-the-counter medications, herbal/alternative medications as well as vitamin/supplement use.
· Include Name of medication, Dosage, Route, frequency.
ALLERGIES:
· Include medications, foods, and chemicals such as latex.
· Include reaction type in parenthesis.
· Example: Penicillin (Hives)
Immunizations History: list current immunization status and address deficiency
health maintenance: (See Table below – Appendix A)
· List any age appropriate health maintenance due/recommended in list format.
SOCIAL HISTORY:
· An acronym that may be used here is HEADSS which stands for Home and Environment; Education, Employment, Eating; Activities; Drugs/Alcohol; Sexuality.
· Employment/Education should include: occupation (type), exposure to harmful agents, highest school achievement
REVIEW OF SYSTEMS:
· A ROS is a question-seeking inventory by body systems to identify signs and/or symptoms that the patient may be experiencing or has experienced that may or may not correlate with the CC.
*If a + finding is found not related to the cc this may represent an additional problem that will need to be detailed in the HPI.
· Must include any physical complaint(s) by the body system that is relevant to the treatment and management of the current concern(s). List only the pertinent body systems specific to the CC.
· Remember to include pertinent positive and negative findings when detailing the ROS related to a chief concern (cc).
· Pertinent positives should be documented first.
· Do not repeat the information provided in HPI
· Documented as “Reports” or “Denies”
Example of an exemplary negative ROS for a Comprehensive Note.
General: Denies malaise, weakness, fever, or chills. Denies recent weight gains or losses of >20 pounds over the last 6 months.
Eyes: Denies change in vision or loss of vision, eye pain, sensitivity, or discharge.
Ears, nose, mouth & throat: Denies ear pain, loss of or decreased hearing, ringing of the ears, drainage from the ears. Denies change in sense of smell, nose bleeds, sinus or facial pain, speaking problems, hoarseness or choking, dry mouth, dental problems, or difficulty chewing or swallowing.
Cardiovascular: Denies chest discomfort, heaviness, or tightness. Denies abnormal heartbeat or palpitations. Denies shortness of breath, denies having to sleep elevated on 2 pillows or more, no swelling of the feet, no passing out or nearly passing out. Denies history of heart attack or heart failure.
Respiratory: Denies cough, phlegm production, coughing up blood, wheezing, sleep apnea, exposure to inhaled substances in the workplace or home, no known exposure to TB or travel outside the country. Denies history of asthma, COPD/emphysema or any other chronic pulmonary disease.
Gastrointestinal: Denies nausea, vomiting, abdominal discomfort/pain. Denies diarrhea, constipation, blood in the stool or black stools. Denies hemorrhoids, trouble swallowing, heartburn or food intolerance. Denies history of liver or gallbladder disease. No recent weight gains or losses of > 20 pounds within the last year.
Skin & Breasts: Denies rash, itching, abnormal skin, or recent injury. Denies breast pain, discharge, or other abnormality was reported by the patient.
Musculoskeletal: Denies muscle or joint pain, back or neck pain, and denies recent accidents or injuries. Denies physical disability or condition that limits activity or ADLs.
Allergic: Denies history of seasonal allergies, allergic rhinitis, watery eyes, or wheezing. Denies history of HIV, hepatitis, shingles, or recurrent infections
Immunologic: Denies history of HIV, TB, hepatitis, shingles, or other recurrent infectious diseases. Denies history of cancer – radiation or chemotherapy.
Endocrine: Denies polyuria, polydipsia, and polyphagia. Denies history of blood sugar instability. Denies temperature intolerance to hot or cold. Denies swelling of the neck or nodules.
Hematopoietic/Lymphatic: Denies unusual lumps or masses. Denies bruising quickly or bleeding easily. Denies history of anemia or recent blood transfusions. Denies sickle cell disease or trait. Denies blood dyscrasias.
Genitourinary: Denies dysuria, frequency, or urgency. Denies abnormal vaginal/penile discharge or bleeding. Denies recent history of bladder or kidney infections/stones. Denies sexual dysfunction or concerns.
Neurological: Denies unusual headaches, history of head injury or loss of consciousness, lightheadedness, dizziness, vertigo. Denies numbness of a body part or weakness on one side of the body. Denies pins and needle sensation, abnormal movements, or seizure disorder. Denies previous strokes, seizures or neurological disorders.
Psychiatric/Mental Status: Denies history of depression or anxiety. Denies difficulty sleeping, persistent thoughts or worries, decrease in sexual desire, abnormal thoughts, visual or auditory hallucinations. Denies history of psychosis or schizophrenia. Denies difficulty concentrating or change in memory.
Objective
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure. Heart rate. Respirations. SaO2 (on room air or O2). Temperature. Weight. Height. BMI.
Example of exemplar PE for a Comprehensive Note with no abnormal findings.
CONSTITUTIONAL/general appearance: Vital signs stable, in no acute distress. Alert, well developed, well nourished.
HEENT:
Head: Atraumatic, normocephalic.
Eyes: Sclerae were white. Conjunctivae and lashes were clear. No lid lag. Extraocular movements were intact (EOMI). PERRLA.
ENT: Ears, nose, mouth, and throat: Mucous membranes were pink, moist and intact. External ear canals were clear without cerumen. TMs were clear, pearly gray with good light reflex bilaterally. Hearing was intact to whisper. Nares patent and mucosa is pink, moist and intact. Mouth, lips and tongue, gums were intact with no lesions. Good dentition. Hard and soft palates intact. Tongue and uvula midline.
NECK: Supple. No JVD, thyromegaly or lymphadenopathy.
RESPIRATORY/CHEST: Unlabored. Chest rise is equal and symmetric. Lungs are CTA bilaterally with no adventitious breath sounds.
CARDIOVASCULAR: S1, S2 without murmurs, rubs or gallops appreciated.
Breasts: Skin intact without lesions, masses, or rashes. No nipple discharge. Breasts with slight asymmetry, no dimpling, retractions or peau d’orange appearance.
GI: Normoactive bowel sounds. No hepatosplenomegaly on exam. No tenderness, masses, or hernias appreciated.
Genital/rectal: no suprapubic tenderness or bladder bulges. No lesions, rashes, masses or swelling.
Lymph nodes: No enlarged glands of the neck, axilla or groin.
MUSCULOSKELETAL: Gait and station were within normal limits. Full range of motion in all joints. Muscle strength and tone were 5/5 all groups. Equal arm swing.
INTEGUMENTARY: Skin was warm and intact. No rashes, lesions, masses or discoloration. No abnormalities to fingers or toenails noted.
EXTREMITIES: No cyanosis or clubbing. No edema of the extremities. Pulses +2 bilaterally radial and pedal.
Neuro: Cranial nerves are intact grossly, II-XII. DTRs intact, +2 bilaterally with symmetric response. Sensation intact to light touch. No motor or sensory deficits.
PSYCH: A&O x3. Recent and remote memory intact. Mood and affect appropriate during visit. Judgment and insight were within normal limits at the time of visit.
*Full mini-mental status exam may be indicated based on the CC or findings in the ROS or physical exam.
Assessment (Diagnosis)
Differential Diagnosis (DDx)
· Include two (2) differential diagnoses you considered but did not select as the final diagnosis. Why were these 2 diagnoses not selected? Support with pertinent positive and negative findings for each differential with an evidence-based guideline(s) (required).
Working or Final Diagnosis:
· Final or working diagnosis (1) (including ICD-10 code)
· Provide a rational explanation supported by evidenced-based guidelines (required). List the pertinent positive and negative symptoms/signs that support your final diagnosis.
Plan
Treatment (Tx) Plan: pharmacologic and/or nonpharmacologic
· Diagnostics. Any labs, imaging, ordered? Remember you are managing this patient in the outpatient/clinic setting, not the hospital.
· Pharmacologic -include full prescribing information for each medication(s) ordered. Name of Medication, Dosage, Route, Frequency, Duration, number of tabs prescribed, number of refills.
Patient Education:
· include specific education related to each medication prescribed.
· Was risk versus benefit of current treatment plan addressed for medication(s) and interventions? Was the patient included in the medical decision making and in agreement with the final plan?
· NPs should not be prescribing non-FDA approved medications or medications related to off-label use. If a physician prescribed a non-FDA-approved medication for working diagnosis or recommended off-label use, was education provided and was the risk to benefit of the medication(s) addressed in the patient’s education?
Referral/Follow-up
· When would you like the patient to be seen in clinic again. Did you recommend follow-up with PCP, or other healthcare professionals/specialists?
· When is the subsequent follow-up?
Reference(s)
· Include APA formatted references for written assignments.
· Minimum 2 references are required from evidence-based resources.
APPENDIX A
Health Maintenance (Example – not all-inclusive)
| Preventive Care |
| Pap |
| Mammogram |
| A1C |
| Eye Exam |
| Monofilament Test |
| Urine
Microalbumin |
| Diet/Lifestyle Changes |
| Digital Rectal Exam (DRE) |
| PSA |
| Colonoscopy or FOBT |
| Dexa Scan |
| CXR |
| BNP |
| ECG |
| Echo |
| Stress
Test |
| Vaccines |
