Episodic\/Focused SOAP Note Template<\/p>\n
Patient Information:
\nInitials, Age, Sex, Race
\nPatient Initials: A.L.\t\tAge: 13\t\t\tGender: Female
\nSUBJECTIVE DATA: : Include what the patient tells you, but organize the information
\nCC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient\u2019s own words – for instance “headache”, NOT “bad headache for 3 days\u201d.
\nChief Complaint (CC): Stomach ache, diarrhea
\nHPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was \u201cheadache\u201d, the LOCATES for the HPI might look like the following example:
\nLocation: head
\nOnset: 3 days ago
\nCharacter: pounding, pressure around the eyes and temples
\nAssociated signs and symptoms: nausea, vomiting, photophobia, phonophobia
\nTiming: after being on the computer all day at work
\nExacerbating\/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
\nSeverity: 7\/10 pain scale
\nHistory of Present Illness (HPI): This 13 -year old female accompanied by her mother presents with complaints of intermittent abdominal pain with episodes of diarrhea for the past 6 days. She recalls eating at a hibachi grill prior to the onset of symptoms begin. Consuming food is an aggravating factor. No relieving factors. Severity of pain 5\/10.<\/p>\n
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
\nAllergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
\nPMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed<\/p>\n
Past Surgical History (PSH):
\nSexual\/Reproductive History:<\/p>\n
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text\/cell phone use while driving, and support system.
\nImmunization History: Include last Tdap, Flu, pneumonia, etc.
\nFam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
\nReview of Systems: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
\nExample of Complete ROS:
\nGENERAL: No weight loss, fever, chills, weakness or fatigue.
\nHEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
\nSKIN: No rash or itching.
\nCARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
\nRESPIRATORY: No shortness of breath, cough or sputum.
\nGASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
\nGENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM\/DD\/YYYY.
\nNEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
\nMUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
\nHEMATOLOGIC: No anemia, bleeding or bruising.
\nLYMPHATICS: No enlarged nodes. No history of splenectomy.
\nPSYCHIATRIC: No history of depression or anxiety.
\nENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
\nALLERGIES: No history of asthma, hives, eczema or rhinitis.
\nOBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P- only in this course. Do not use \u201cWNL\u201d or \u201cnormal.\u201d You must describe what you see.
\nPhysical Exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use \u201cWNL\u201d or \u201cnormal.\u201d You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
\nVital signs: Include vital signs, ht, wt, and BMI.
\nGeneral: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of consciousness, and affect and reactions to people and things.
\nHEENT:
\nNeck:
\nChest
\nLungs:
\nHeart
\nPeripheral Vascular: Abdomen:
\nGenital\/Rectal:
\nMusculoskeletal:
\nNeurological:
\nSkin:
\nDiagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
\nASSESSMENT: List your priority diagnosis (es). For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.
\nDifferential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
\nPLAN: Include additional laboratory and diagnostic tests, consults, therapeutic modalities, health promotion patient education as well as disposition\/follow up instructions as they pertain to your patients\u2019 assessment.
\nTreatment Plan: If applicable, include both pharmacological and non-pharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.<\/p>\n
Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient\/family. Support the health promotion recommendations and strategies with evidence and guidelines.<\/p>\n
Disease Prevention: As appropriate for the patient\u2019s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.<\/p>\n
REFLECTION: Document what you learned from this experience? Any ah-ha\u2019s?<\/p>\n
References
\nYou are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.<\/p>\n","protected":false},"excerpt":{"rendered":"
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