mini soap note

Mini-SOAP note on a patient that you saw in clinic this week. Submit as a Word Document.

Review the rubric for more information on how your assignment will be graded.

Demographic Data

Age, and gender (must be HIPAA compliant)

Subjective

  • Chief Complaint (CC) unless an Annual Physical Exam (APE)
  • History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)

    Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance as applicable

  • Family Hx: As applicable
  • Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
  • Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
  • Objective

  • Vital signs
  • Physical findings listed by body systems, not paragraph form
  • Assessment (Diagnosis/ICD10 Code)
  • Include all diagnoses that apply for this visit

    Plan

  • Dx Plan (lab, x-ray)
  • Tx Plan: (meds)

  • Pt. Education, including specific medication teaching points
  • Referral/Follow-up

    Adult Gero SOAP Note Template
    Use this template for Comprehensive Notes (Initial Comprehensive/
    Annual visit) and Problem-Focused Notes (Episodic/progress notes).
    For the Problem-Focused Notes, only include pertinent problemfocused information related to the chief concern (CC).
    Demographic Data
    o
    Patient age and gender identity
    o
    MUST BE HIPAA compliant
    Subjective
    Chief Complaint (CC)
    o
    o
    o
    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
    o Briefly describe the general state of health prior to the
    problem.
    o
    PAST MEDICAL HISTORY:
    o List current and past medical diagnoses (in list format)
    PAST SURGICAL HISTORY:
    o List all past surgeries including dates (in list format)
    FAMILY HISTORY:
    o Include medical/psychiatric problems to include 2 generations
    (parents, grandparents, siblings, or direct relatives (in list
    format).
    CURRENT MEDICATIONS:
    o Include current prescription(s), over-the-counter medications,
    herbal/alternative medications as well as vitamin/supplement
    use.
    o Include Name of medication, Dosage, Route, frequency.
    ALLERGIES:
    o Include medications, foods, and chemicals such as latex.
    o Include reaction type in parenthesis.
    o Example: Penicillin (Hives)
    IMMUNIZATIONS HISTORY: list current immunization status and
    address deficiency
    HEALTH MAINTENANCE: (See Table below – Appendix A)
    o 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.
    o Employment/Education should include: occupation
    (type), exposure to harmful agents, highest school
    achievement
    o
    REVIEW OF SYSTEMS:
    o 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.
    o 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.
    o Remember to include pertinent positive and negative findings
    when detailing the ROS related to a chief concern (cc).
    o Pertinent positives should be documented first.
    o Do not repeat the information provided in HPI
    o 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)
    o
    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:
    o Final or working diagnosis (1) (including ICD-10 code)
    o 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.
    o Pharmacologic -include full prescribing information for each
    medication(s) ordered. Name of Medication, Dosage, Route,
    Frequency, Duration, number of tabs prescribed, number of
    refills.
    o
    Patient Education:
    o include specific education related to each medication
    prescribed.
    o 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?
    o
    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
    o When would you like the patient to be seen in clinic again. Did
    you recommend follow-up with PCP, or other healthcare
    professionals/specialists?
    o When is the subsequent follow-up?
    Reference(s)
    o Include APA formatted references for written assignments.
    o 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
    The Prevention TaskForce (formerly ePSS) application assists primary care
    clinicians to identify the screening, counseling, and preventive medication services
    that are appropriate for their patients.
    Download this app and be sure to reference when assessing Health Maintenance
    priorities for your patients:
    https://www.uspreventiveservicestaskforce.org/apps/

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