Health & Medical Question

patient soap not assignment written communication. I uploaded the guide and every thing you need it.

Patient initials, date, location (if applicable)
SOAP Note Template with supplemental comments; skeleton template on next page
Do NOT submit a SOAP note with these supplemental comments/prompts
S:
CC: [Chief Complaint: May be a quote from the patient (usually about a symptom or new
problem) or simply the reason for the visit. Only include information pertinent to the visit.]
HPI: [History of Present Illness: A narrative related to the CC, the purpose of which is to provide
background information pertinent to the visit. Only include information pertinent to the visit.]
FH: [Family History: Medical information for blood relatives; may write in list or sentence form;
only include information pertinent to the visit; if unknown or noncontributory, state as such.]
SH: [Social History: May include occupation, living situation, level of education, exercise status,
use of alcohol/tobacco/illicit drugs. Diet may also be included here or described as part of HPI. If
diet is explained sufficiently in HPI, could simply state, “Diet as per HPI” in the SH section. May
write in list or sentence form; only include information pertinent to the visit; if unknown or
noncontributory, state as such.]
ROS: [Review of Systems: Subjective patient-reported symptoms; may write in list or sentence
form; only include information pertinent to the visit; if unknown or noncontributory, state as
such.]
PMH: [Past Medical History: A list of medical problems/diagnoses with duration or dates of
diagnosis if known. You may write this in sentence form if you desire, but simply a list is
sufficient. Only include information pertinent to the visit.]
Meds: [Medications: List ALL medications. Include full sig of drug, dose, route, frequency,
duration (if not chronic).]
Immunizations: [List ALL immunization with dates if known.]
ALL: [Allergies: List ALL allergies. Include offending agent and reaction (if known) in
parentheses. Note if it is an intolerance.]
O:
VS: [Vital Signs: Generally, includes height and weight, often written as: BP x, P x, RR x, T x, Ht
x, Wt x, BMI x. Include units for Ht & Wt. Include the most recent value of each, including the
date. If any are not known, delete the individual prompt; however, do calculate and include BMI
if Ht and Wt are available.]
PE: [Physical Examination: Only include information pertinent to the visit.]
Labs: [Include actual lab values with units; do NOT state “WNL.” Always include calculated CrCl
(with or without eGFR) if SCr is available. Include dates of labs if different from your encounter
date. Only include information pertinent to the visit.]
Diagnostic tests: [Only include information pertinent to the visit. If not needed, may delete the
“Diagnostic tests” prompt. (This ONLY applies to the “Diagnostic tests” prompt; all other
prompts/sections should remain in the note.)]
A: [Assessment should justify the plan! Put the pt’s identified problems in a prioritized list (from
most acute/important to least pressing). Include goals of therapy, pertinent +/-, considerations
for therapy. Cite guidelines & primary literature as appropriate.]
1. [Problem 1 with goals of therapy, assessment of the problem and current treatment, and
justification/rationale for continuation of or changes to treatment with appropriate
references]
2. [Problem 2 with goals of therapy, assessment of the problem and current treatment, and
justification/rationale for continuation of or changes to treatment with appropriate
references]
P: [Plan should include specific, clear, easy-to-follow action items. Plan should be in same order
as A, but not necessary one-for-one (i.e., may have multiple action items for one problem; could
[Name], PharmD Candidate, Class of ____
Patient initials, date, location (if applicable)
put follow-up as last in list even though it may relate to multiple problems). Include
pharmacological (full sig/order) and non-pharmacological interventions, counseling/education,
monitoring, follow-up.]
1. [Problem 1 with treatment plan, safety/efficacy counseling, non-pharmacological
interventions, and safety and efficacy monitoring]
2. Problem 2 with treatment plan, safety/efficacy counseling, non-pharmacological
interventions, and safety and efficacy monitoring]
• Preventative Health: [Include any recommendations for immunizations, routine health
screenings, and/or lifestyle changes]
• Follow-up/Referral: [State when patient should follow up with provider and any specific
actions that need to be taken at that follow up, make referrals to any additional providers
that may be out of the scope of the pharmacist at this visit]
Formatting instructions:
Format: Header includes patient initials, date, and location. Footer includes student name
and credentials. Submits as a word document with a length that does not exceed 2 singlespaced pages utilizing 11-point Arial font and 1-inch margins.
Readability: Utilizes appropriate medical language, grammar, spelling, and abbreviations
(see lists from ISMP and Joint Commission for do not use abbreviation lists) throughout the
note. Written so that it can easily be read and understood by a medical provider.
• Full credit if no errors and easily read without having to re-read for understanding
message.
• Half credit if 1 error or requires 1 re-read to understand message.
• No credit if 2 or more errors or requires 2 or more re-reads to understand message.
[Name], PharmD Candidate, Class of ____
Patient initials, date, location (if applicable)
S:
CC:
HPI:
FH:
SH:
ROS:
PMH:
Meds:
Immunizations:
ALL:
O:
VS:
PE:
Labs:
Diagnostic tests: (may delete this prompt if no diagnostic tests are available or they are not
pertinent to your encounter)
A:
1.
2.
P:
1. Problem 1: Treatment Plan
Counseling:
Nonpharm:
Monitoring:
2. Problem 2: Treatment Plan:
Counseling:
Nonpharm:
Monitoring:
• Preventative Health:
• Follow-up/Referral:
[Name], PharmD Candidate, Class of ____
SOAP Notes
Sarah M Anderson, PharmD
PCS 7330 Introduction to Therapeutics
2023
Discuss
Differentiate
Determine
Discuss the importance of documentation in the patient care setting
Differentiate between the sections of a SOAP note
Determine what information should go in each section
If you didn’t write it, it
didn’t happen!
▪ History & Physical = comprehensive note of all current and past
medical history, typically completed at initial encounter by patient’s
primary care physician
▪ Progress note = comprehensive note of all current medical problems,
typically completed for subsequent encounters; may be done by a
pharmacist
▪ Consult note = abbreviated note focused on a specific medical
problem or set of problems for which a clinician has been consulted
to assess; may be done by a pharmacist
▪ Academic SOAP note = most like a progress note addressing all
current medical problems, also includes detailed rationale and
justification for clinical decisions
Sherrill. 2022
S
O
A
P
Subjective
S
Subjective
O
Objective
A
P
S
Subjective
O
Objective
A
Assessment
P
S
Subjective
O
Objective
A
Assessment
P
Plan
1
+
2-
Positive: Helps to rule in
a particular condition
Negative: Helps to rule
out a particular
condition
SUBJECTIVE
▪ Chief Complaint
▪ Quote from the patient (usually about a symptom or new problem)
OR
“I have an itchy, dry, and
red rash on my arm”
▪ Reason for the visit
OR
Dermatitis
▪ History of Present Illness
▪ A narrative or story related to the chief complaint
▪ This should only include pertinent information
A week ago, patient stated
a red, itchy, dry rash
started to appear on their
arm. They tried putting
Neosporin on their arm,
but had no success. The
rash started off smaller
but has increased in size
to about the size of the
palm of their hand. It
seems to be worse since
winter has started and
they have begun using
more heat at home. He
also started a new
gardening job and has
been trimming a lot of
trees lately. He thinks he
may be allergic to
something.
▪ Family History
▪ Medical information from blood relatives
▪ This can be listed!
▪ If it is unknown or noncontributory, state that in the section
▪ Important: this is only about medical information, living situations and/or
relationships are not included here
▪ If a patient is adopted and they do not know any blood relatives→
Unknown
FH: Mother (Asthma – 1988, dermatitis – 1991); Father
(Asthma – 1987, allergic rhinitis – 1980)
▪ Social History
SH: Gardener
▪ Occupation
▪ Living situation
▪ Level of education
▪ Exercise
▪ Diet
▪ Substance use: alcohol, tobacco, illicit drugs, caffeine
▪ If unknown or noncontributory, state that in the section
▪ Review of systems
▪ Constitutional
▪ HEENT
▪ Respiratory
ROS:
Integumentary: dry, red,
itchy rash on right arm
▪ Cardiovascular
▪ Gastrointestinal
▪ Genitourinary
▪ Metabolic/endocrine
▪ Neurological
▪ Psychiatric
▪ Integumentary (skin)
▪ Musculoskeletal
chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://health.uconn.edu/plastic-surgery/wpcontent/uploads/sites/132/2017/06/review_of_systems.pdf
▪ Past medical history
▪ List of medical problems
▪ Include date of diagnosis if known
PMH: GERD (2019), Asthma (2001), allergic rhinits (2000)
▪ Include full sig of drug, dose, route, frequency, duration
▪ Include all medications
▪ Include adherence if known
Meds: Albuterol inhaler,
inhale 1 puff by mouth
every 4-6 hours as needed;
Zyrtec 10 mg PO daily
▪ List known immunizations the patient has received with dates
Immunizations: Influenza
(2022); COVID (2021,
booster 2022)
▪ List ALL allergies
▪ Include offending agent and reaction (if known) in parentheses
▪ Note if it is an intolerance
Allergies: Pollen (sneezing,
difficulty breathing);
Hydrocodone (intolerance,
upset stomach)
OBJECTIVE
▪ Vital signs
▪ Blood pressure (BP)
▪ Pulse (P)
▪ Respiratory rate (RR)
▪ Temperature (T)
▪ Height (Ht)
▪ Weight (Wt)
▪ Body mass index (BMI)
▪ Calculate and include when Ht and Wt are given
▪ weight (kg) / [height (m)]2 OR 703 x weight (lbs) / [height (in)]2
VS: BP 118/64 P 78 RR 10
T 98.1F Ht 67’’ Wt 180lb
BMI 28.2
▪ Physical exam
▪ Looks like ROS headers, but includes what has been observed by medical
professional
PE:
Integumentary: red rash
with several papules; (-)
scratching or oozing
▪ Include actual lab values
▪ Include units
▪ Do not state WNL (this is an assessment)
▪ Calculate CrCl when SCr is given
▪ Include dates if different from the current date (historical values)
▪ Labs are not done for self-care treatment
Labs: WBC 10 cells/μL
▪ CT
▪ MRI
▪ Colonoscopy
▪ Ultrasound
▪ Eye tests
▪ Diagnostic tests are not done for self-care treatment
ASSESSMENT
▪ Arrange from most urgent/pressing to least
1.
2.
3.
Dermatitis: …
Asthma: …
Allergic rhinitis: …
▪ From credible source (guidelines), what are the specific goals for this
condition
▪ Short and long term goals
Dermatitis: resolution of acute
flare-up, maintain moisture to
prevent future flare-ups
▪ Using the S/O information and diagnostic/staging criteria, state the patient’s
current condition using these variables
▪ Information from S/O should be interpreted in this stage
▪ State whether uncontrolled or controlled
▪ Remember to state what medications the patient is on for that condition or if
any drug interactions exist
Dermatitis, uncontrolled: Patient presents with dry, red,
itchy rash with multiple papules. Patient’s family and
personal history of asthma and allergic rhinitis indicates
the patient is suffering from an acute flare-up of atopic
dermatitis. Patient is negative for scratches or oozing,
indicating that an infection is unlikely present. Patient is
currently not on any medications.
▪ List all first line agents (or the next line of therapy if on existing treatment)
▪ Include why or why not each would be acceptable for the patient
Dermatitis: First-line therapy includes topical
corticosteroids, emollients (petrolatum or ceramide
containing), and moisturizers. Topical corticosteroids
avoid systemic absorption and are effective in reducing
redness and itchiness of rash. Both petrolatum and
ceramide-containing emollients would be effective;
however, ceramides help prevent moisture loss and help
to repair skin.
PLAN
▪ Be clear and concise
▪ Full SIGs are necessary
▪ Dosing should be provided, ranges are not acceptable
▪ Have an action word for any medications that are recommended: Start,
Discontinue, Continue
1. Dermatitis: Start hydrocortisone 1% cream: Apply a
thin layer cream to affected area on the arm 1-2 times a
day for 7 days.
▪ Provide 2-3 major counseling points related to the drug
Counseling: Stop using hydrocortisone daily after 7 days,
if necessary, may use 1-2 times weekly or as needed with
flare-ups. Wash hands before and after application. Apply
before using an emollient.
▪ Add any nonpharmacologic options to this section
▪ This may or may not be included depending on what the condition is
Nonpharm: Use mild non-soap cleaners, apply moisturizer
immediately after bathing with lukewarm water. Avoid
scented, chemical laundry detergents and triggers
▪ Safety
▪ Is the patient having any ADRs
▪ How would you observe for these?
▪ Labs
▪ PE
▪ Diagnostics
▪ Ask the patient!
▪ Efficacy
▪ Is the intervention doing what you desire it to do?
▪ Labs
▪ PE
▪ Diagnostics
▪ Ask the patient!
▪ Include relevant time frames as needed
Monitoring: improvement of
rash, specifically redness and
itchiness
▪ Include information that is applicable to
▪ Lifestyle changes
▪ Diet
▪ Exercise
▪ Routine Screenings
▪ Physical
▪ Colonoscopy
▪ Pap smear
▪ Etc.
▪ Immunizations
▪ Review the immunizations and make recommendations
▪ Utilize CDC Immunization schedules
PH: Increase water intake.
Review immunizations upon
next visit when patient brings
history.
▪ What is the soonest they need to come back?
▪ Do they need to seek alternative care?
▪ Specialist
▪ Dietician
▪ Counseling
Follow-up in 7 days. No improvement in 7 days, refer to
PCP or dermatologist.
Specific
Accurate
Concise
Thorough
Connected
Adopted
father (MI
at age 50)
K 5.0 mEq/L
Lives with 2
children
Patient:
“having
trouble
breathing”
Hyperkale
mic (K 5.0)
BP 150/78
Discontinue
Ibuprofen
200mg
HTN (2012)
Drinks wine
2x/week
“I keep
belching and
having
heartburn
every time I
eat buffalo
wings.”
Questions
Take one of your written
communications from Clinical
Skills Lab II and reformat it
into the SOAP template
Turn into blackboard
SOAP Notes
Sarah M Anderson, PharmD
PCS 7330 Introduction to Therapeutics
2023
▪ Please welcome our Special Guests!
Discuss
Differentiate
Determine
Discuss the importance of documentation in the patient care setting
Differentiate between the sections of a SOAP note
Determine what information should go in each section
If you didn’t write it, it
didn’t happen!
▪ History & Physical = comprehensive note of all current and past
medical history, typically completed at initial encounter by patient’s
primary care physician
▪ Progress note = comprehensive note of all current medical problems,
typically completed for subsequent encounters; may be done by a
pharmacist
▪ Consult note = abbreviated note focused on a specific medical
problem or set of problems for which a clinician has been consulted
to assess; may be done by a pharmacist
▪ Academic SOAP note = most like a progress note addressing all
current medical problems, also includes detailed rationale and
justification for clinical decisions
Sherrill. 2022
S
O
A
P
Subjective
S
Subjective
O
Objective
A
P
S
Subjective
O
Objective
A
Assessment
P
S
Subjective
O
Objective
A
Assessment
P
Plan
SUBJECTIVE
1
+
2-
Positive: Helps to rule in
a particular condition
Negative: Helps to rule
out a particular
condition
▪ Chief Complaint
▪ Quote from the patient (usually about a symptom or new problem)
OR
“I have an itchy, dry, and
red rash on my arm”
▪ Reason for the visit
OR
Dermatitis
▪ History of Present Illness
▪ A narrative or story related to the chief complaint
▪ This should only include pertinent information
A week ago, patient stated
a red, itchy, dry rash
started to appear on their
arm. They tried putting
Neosporin on their arm,
but had no success. The
rash started off smaller
but has increased in size
to about the size of the
palm of their hand. It
seems to be worse since
winter has started and
they have begun using
more heat at home. He
also started a new
gardening job and has
been trimming a lot of
trees lately. He thinks he
may be allergic to
something.
▪ Family History
▪ Medical information from blood relatives
▪ This can be listed!
▪ If it is unknown or noncontributory, state that in the section
▪ Important: this is only about medical information, living situations and/or
relationships are not included here
▪ If a patient is adopted and they do not know any blood relatives→
Unknown
FH: Mother (Asthma – 1988, dermatitis – 1991); Father
(Asthma – 1987, allergic rhinitis – 1980)
▪ Social History
SH: Gardener
▪ Occupation
▪ Living situation
▪ Level of education
▪ Exercise
▪ Diet
▪ Substance use: alcohol, tobacco, illicit drugs, caffeine
▪ If unknown or noncontributory, state that in the section
▪ Review of systems
▪ Constitutional
▪ HEENT
▪ Respiratory
ROS:
Integumentary: dry, red,
itchy rash on right arm
▪ Cardiovascular
▪ Gastrointestinal
▪ Genitourinary
▪ Metabolic/endocrine
▪ Neurological
▪ Psychiatric
▪ Integumentary (skin)
▪ Musculoskeletal
chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://health.uconn.edu/plastic-surgery/wpcontent/uploads/sites/132/2017/06/review_of_systems.pdf
▪ Past medical history
▪ List of medical problems
▪ Include date of diagnosis if known
PMH: GERD (2019), Asthma (2001), allergic rhinits (2000)
▪ Include full sig of drug, dose, route, frequency, duration
▪ Include all medications
▪ Include adherence if known
Meds: Albuterol inhaler,
inhale 1 puff by mouth
every 4-6 hours as needed;
Zyrtec 10 mg PO daily
▪ List known immunizations the patient has received with dates
Immunizations: Influenza
(2022); COVID (2021,
booster 2022)
▪ List ALL allergies
▪ Include offending agent and reaction (if known) in parentheses
▪ Note if it is an intolerance
Allergies: Pollen (sneezing,
difficulty breathing);
Hydrocodone (intolerance,
upset stomach)
OBJECTIVE
▪ Vital signs
▪ Blood pressure (BP)
▪ Pulse (P)
▪ Respiratory rate (RR)
▪ Temperature (T)
▪ Height (Ht)
▪ Weight (Wt)
▪ Body mass index (BMI)
▪ Calculate and include when Ht and Wt are given
▪ weight (kg) / [height (m)]2 OR 703 x weight (lbs) / [height (in)]2
VS: BP 118/64 P 78 RR 10
T 98.1F Ht 67’’ Wt 180lb
BMI 28.2
▪ Physical exam
▪ Looks like ROS headers, but includes what has been observed by medical
professional
PE:
Integumentary: red rash
with several papules; (-)
scratching or oozing
▪ Include actual lab values
▪ Include units
▪ Do not state WNL (this is an assessment)
▪ Calculate CrCl when SCr is given
▪ Include dates if different from the current date (historical values)
▪ Labs are not done for self-care treatment
Labs: WBC 10 cells/μL
▪ CT
▪ MRI
▪ Colonoscopy
▪ Ultrasound
▪ Eye tests
▪ Diagnostic tests are not done for self-care treatment
ASSESSMENT
▪ Arrange from most urgent/pressing to least
1.
2.
3.
Dermatitis: …
Asthma: …
Allergic rhinitis: …
▪ From credible source (guidelines), what are the specific goals for this
condition
▪ Short and long term goals
Dermatitis: resolution of acute
flare-up, maintain moisture to
prevent future flare-ups
▪ Using the S/O information and diagnostic/staging criteria, state the patient’s
current condition using these variables
▪ Information from S/O should be interpreted in this stage
▪ State whether uncontrolled or controlled
▪ Remember to state what medications the patient is on for that condition or if
any drug interactions exist
Dermatitis, uncontrolled: Patient presents with dry, red,
itchy rash with multiple papules. Patient’s family and
personal history of asthma and allergic rhinitis indicates
the patient is suffering from an acute flare-up of atopic
dermatitis. Patient is negative for scratches or oozing,
indicating that an infection is unlikely present. Patient is
currently not on any medications.
▪ List all first line agents (or the next line of therapy if on existing treatment)
▪ Include why or why not each would be acceptable for the patient
Dermatitis: First-line therapy includes topical
corticosteroids, emollients (petrolatum or ceramide
containing), and moisturizers. Topical corticosteroids
avoid systemic absorption and are effective in reducing
redness and itchiness of rash. Both petrolatum and
ceramide-containing emollients would be effective;
however, ceramides help prevent moisture loss and help
to repair skin.
PLAN
▪ Be clear and concise
▪ Full SIGs are necessary
▪ Dosing should be provided, ranges are not acceptable
▪ Have an action word for any medications that are recommended: Start,
Discontinue, Continue
1. Dermatitis: Start hydrocortisone 1% cream: Apply a
thin layer cream to affected area on the arm 1-2 times a
day for 7 days.
▪ Provide 2-3 major counseling points related to the drug
Counseling: Stop using hydrocortisone daily after 7 days,
if necessary, may use 1-2 times weekly or as needed with
flare-ups. Wash hands before and after application. Apply
before using an emollient.
▪ Add any nonpharmacologic options to this section
▪ This may or may not be included depending on what the condition is
Nonpharm: Use mild non-soap cleaners, apply moisturizer
immediately after bathing with lukewarm water. Avoid
scented, chemical laundry detergents and triggers
▪ Safety
▪ Is the patient having any ADRs
▪ How would you observe for these?
▪ Labs
▪ PE
▪ Diagnostics
▪ Ask the patient!
▪ Efficacy
▪ Is the intervention doing what you desire it to do?
▪ Labs
▪ PE
▪ Diagnostics
▪ Ask the patient!
▪ Include relevant time frames as needed
Monitoring: improvement of
rash, specifically redness and
itchiness
▪ Include information that is applicable to
▪ Lifestyle changes
▪ Diet
▪ Exercise
▪ Routine Screenings
▪ Physical
▪ Colonoscopy
▪ Pap smear
▪ Etc.
▪ Immunizations
▪ Review the immunizations and make recommendations
▪ Utilize CDC Immunization schedules
PH: Increase water intake.
Review immunizations upon
next visit when patient brings
history.
▪ What is the soonest they need to come back?
▪ Do they need to seek alternative care?
▪ Specialist
▪ Dietician
▪ Counseling
Follow-up in 7 days. No improvement in 7 days, refer to
PCP or dermatologist.
Specific
Accurate
Concise
Thorough
Connected
Adopted
father (MI
at age 50)
K 5.0 mEq/L
Lives with 2
children
Patient:
“having
trouble
breathing”
Hyperkale
mic (K 5.0)
BP 150/78
Discontinue
Ibuprofen
200mg
HTN (2012)
Drinks wine
2x/week
“I keep
belching and
having
heartburn
every time I
eat buffalo
wings.”
Questions
Form a team of 4-6 people. Create a
written communication, using the SOAP
template, to plan out a game night. Be
creative and include something for each
section/subsection.
Turn into blackboard
OOC4
Scope: You are a retail pharmacist with no collaborative practice agreements. It is another busy
day, and a patient is presenting for your advice for something over the counter for something
to help her son.
Colin Clark
DOB: 11/22/2019
Ht: 37 inches Wt: 31.8 lb
Medications: None
Allergies: ibuprofen (rash at age 1)
A worried mother reports that her son Colin came home today after preschool complaining of
not feeling well. She noticed Colin seemed more tired than usual and did not have much of an
appetite. She states that before today, Colin was feeling healthy and well. Colin’s mother also
noticed that his forehead felt warm. When she took Colin’s temperature with a tympanic
thermometer, it was 102.4°F. Mom said nothing is making it worse or better than she can
identify. They have not tried anything yet but really need your help. Colin has had a decreased
appetite and normal sleep, but he appears to the mom and you more tired. The daycare
reported he seemed more tired as the day went on, but still played with his friends. You ask
about a rash, and mom says there are none. You ask if there are any other symptoms, and the
mother says no. You take Colin’s temperature with the oral thermometer in your small clinic,
and it reads 102.1F.
Using the SOAP Template, write up your written communication and submit on blackboard
under the “Out of Class Written Communication” Folder at the top of the page.