Assignment Prompt & Instructions
Roch week 4 soap
– a year ago
**files (2)**
– ## annotated-SOAP20NOTE20UNIT204.docx.pdf
– SOAPNoteTemplate-Final28129.docx
**## annotated-SOAP20NOTE20UNIT204.docx.pdf**
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
S: SUBJECTIVE DATA
CC: "My lower back has been hurting for the past two weeks, especially after
long hours at my desk job. I’ve also noticed stiffness in the mornings."
HPI: • O: Gradual onset ~2 weeks ago
• L: Bilateral lower back
• D: Constant ache, worse by end of day
• C: Dull, achy pain
• A: Prolonged sitting, lifting heavy objects
• R: Heat, stretching, ibuprofen
• T: OTC meds, no PT
• S: 32F with lower back pain, likely musculoskeletal
PMH: • Hypertension (controlled, on lisinopril 10mg daily)
• Tonsillectomy at age 12
• No hospitalizations.
ALLERGIES NKDA
MEDICATIONS • Lisinopril 10mg PO daily (for HTN)
• Ibuprofen 400mg PO PRN (for pain)
SH • Occupation: Accountant (sedentary job)
• Non-smoker
• Occasional alcohol use
• Exercises 2x/week (yoga, walking)
• High work-related stress
• No drug use, low HIV risk
• Sexually active; no reported issues
• Moderate caffeine intake likely (desk job)
FH • Maternal: HTN diagnosed at 50, osteoporosis at 65
• Paternal: Type 2 diabetes diagnosed at 55
HEALTH
PROMOTION &
MAINTENANCE
• Immunizations: Flu (2023), COVID-19 booster (2023)
• Diet: Balanced, low sodium
• Exercise: Yoga and walking 2x/week
• Dental: Last exam 6 months ago
• Vision: Eye exam overdue (none in 2+ years)
• Plans for DEXA by age 40
Amanda Huber
109940000000053740
The assignment was to complete an annual wellness/new pt exam
Amanda Huber
109940000000053740
ask all age appropriate questions for screening for a 32 y/o female.
Amanda Huber
109940000000053740
Start with age and gender.
Amanda Huber
109940000000053740
Incorrect HPI for annual wellness/new pt
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
Constitutional No fever, chills, or fatigue
Head No headaches, trauma, or dizziness
Eyes No vision changes, eye pain, or
discharge
Ears, Nose, Mouth, Throat No congestion, sore throat, or ear
symptoms
Neck No stiffness or swelling
Cardiovascular/Peripheral
Vascular
No chest pain, palpitations, or edema
Respiratory Denies coughing, SOB, or wheezing
Breast No lumps or discharge reported
Gastrointestinal No nausea, vomiting, or bowel changes
Genitourinary No dysuria, urgency, or incontinence
Musculoskeletal Reports dull lower back pain, no joint
swelling
Integumentary Denies having rashes, bruising, or
wounds
Neurological No numbness, tingling, or headaches
Psychiatric (screening tools: Ex:
PHQ-9, MMSE, GAD-7)
Feels stressed from work; no
depression or anxiety noted
Endocrine No polydipsia, polyuria, or heat/cold
intolerance
Hematologic/Lymphatic No easy bruising, bleeding, or swollen
nodes
ROS
(put N/A in sections
not completed day of
exam)
Allergic/Immunologic No known allergies or immune
disorders
Other Denies weight changes or urinary
symptoms
O: OBJECTIVE DATA
HR: 72 RR: 16 BP: 118/78 Temp: 98.4°F
SpO2%: 98% Ht: 5'6" Wt: 150 lbs BMI: 24.2
VITALS:
Age: 32 LMP: N/A PAIN:
Reports 4/10
dull lower
back pain
General Appearance Alert, well-nourished, in no acute
distress
Amanda Huber
109940000000053740
why is this NA?
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
Head Normocephalic, atraumatic
Eyes PERRLA, no conjunctival injection
ENT, Mouth Moist mucosa, no erythema or
lesions
Neck Supple, no lymphadenopathy or
thyromegaly
Cardiovascular/Peripheral Vascular Regular rate and rhythm, no
murmurs, pulses intact
Respiratory Clear to auscultation bilaterally, no
rales/wheezes
Breast N/A
Gastrointestinal Soft, non-tender, no
hepatosplenomegaly
Genitourinary Male
• External Exam N/A
• Internal Exam N/A
Genitourinary Female
• External Exam No GU complaints
• Internal Exam Deferred
Musculoskeletal Tender lumbar paraspinals, stiff
flexion, normal ROM, no swelling
Integumentary Skin intact, no lesions or rashes
Neurological Alert, oriented, normal strength
and sensation; negative straight-leg
raise
Psychiatric Appropriate affect; good insight and
judgment
Endocrine No signs of hormonal imbalance
Hematologic/Lymphatic No lymphadenopathy, no bruising
PHYSICAL
EXAM
(Pertinent data
related to
presenting
problem or
visit type. Put
N/A in sections
not completed
day of exam)
Allergic/Immunologic No signs of allergic reaction
Other N/A
A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS ICD-10 CODES
1. Low back pain (musculoskeletal) M54.5PRIORITIZE
DIAGNOSIS
2. Hypertension, controlled I10
Amanda Huber
109940000000053740
not objective data
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
3. Health maintenance (osteoporosis risk) Z79.899
VISIT CODES CPT BILLING CODES 99213 (Established patient, low-
moderate complexity)
POC TESTING None required. No tests today;
imaging if symptoms persist or
worsen
DIAGNOSTICS
TESTS REVIEWED N/A
P: PLAN
1. Diagnosis: Low back pain
Diagnostics Order: Consider lumbar spine X-ray if pain persists
beyond 4 weeks or worsens
Therapeutic: Naproxen 220mg PO BID PRN, continue stretching
and ergonomic adjustments at workstation
Education: Educated on posture, body mechanics, daily stretches;
avoid heavy lifting
Consultation/Collaboration: Refer to physical therapy if no
improvement in 4 weeks.
ACTIONS
2. Diagnosis: Hypertension
Diagnostics Order: Routine BP monitoring every 3–6 months;
annual CMP to monitor kidney function and electrolytes due to
lisinopril use.
Therapeutic: Continue lisinopril 10mg PO daily
Education: Reinforced adherence to low-sodium diet, encouraged
home BP monitoring
Consultation/Collaboration: No referral needed currently. May
consider referral to cardiology if BP control worsens or signs of
target organ damage arise.
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
3. Diagnosis: Health maintenance
Diagnostics Order: Schedule DEXA scan by age 40
Therapeutic: Encourage daily calcium (1000mg) and vitamin D
(800 IU) intake through diet or supplements to reduce osteoporosis
risk.
Education: Recommend eye exam within 6 months; discussed
importance of maintaining routine health screenings and dental
exams.
Consultation/Collaboration: May consider future referral to
ophthalmology if vision changes occur or if eye exam reveals
abnormalities
PREVENTITIVE
(Used for
comprehensive exams)
• Eye exam recommended
• DEXA scan by age 40
• Re-evaluation of back pain in 4 weeks
• Annual wellness visits scheduling
FOLLOW UP Follow-up in 4 weeks to reassess back pain and evaluate if PT or
imaging is needed
**SOAPNoteTemplate-Final28129.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/soapnotetemplate-final28129-docx-10305213)
**SOAPNoteTemplate-Final28129.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/soapnotetemplate-final28129-docx-10305213)
**## annotated-SOAP20NOTE20UNIT204.docx.pdf**
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
S: SUBJECTIVE DATA
CC: "My lower back has been hurting for the past two weeks, especially after
long hours at my desk job. I’ve also noticed stiffness in the mornings."
HPI: • O: Gradual onset ~2 weeks ago
• L: Bilateral lower back
• D: Constant ache, worse by end of day
• C: Dull, achy pain
• A: Prolonged sitting, lifting heavy objects
• R: Heat, stretching, ibuprofen
• T: OTC meds, no PT
• S: 32F with lower back pain, likely musculoskeletal
PMH: • Hypertension (controlled, on lisinopril 10mg daily)
• Tonsillectomy at age 12
• No hospitalizations.
ALLERGIES NKDA
MEDICATIONS • Lisinopril 10mg PO daily (for HTN)
• Ibuprofen 400mg PO PRN (for pain)
SH • Occupation: Accountant (sedentary job)
• Non-smoker
• Occasional alcohol use
• Exercises 2x/week (yoga, walking)
• High work-related stress
• No drug use, low HIV risk
• Sexually active; no reported issues
• Moderate caffeine intake likely (desk job)
FH • Maternal: HTN diagnosed at 50, osteoporosis at 65
• Paternal: Type 2 diabetes diagnosed at 55
HEALTH
PROMOTION &
MAINTENANCE
• Immunizations: Flu (2023), COVID-19 booster (2023)
• Diet: Balanced, low sodium
• Exercise: Yoga and walking 2x/week
• Dental: Last exam 6 months ago
• Vision: Eye exam overdue (none in 2+ years)
• Plans for DEXA by age 40
Amanda Huber
109940000000053740
The assignment was to complete an annual wellness/new pt exam
Amanda Huber
109940000000053740
ask all age appropriate questions for screening for a 32 y/o female.
Amanda Huber
109940000000053740
Start with age and gender.
Amanda Huber
109940000000053740
Incorrect HPI for annual wellness/new pt
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
Constitutional No fever, chills, or fatigue
Head No headaches, trauma, or dizziness
Eyes No vision changes, eye pain, or
discharge
Ears, Nose, Mouth, Throat No congestion, sore throat, or ear
symptoms
Neck No stiffness or swelling
Cardiovascular/Peripheral
Vascular
No chest pain, palpitations, or edema
Respiratory Denies coughing, SOB, or wheezing
Breast No lumps or discharge reported
Gastrointestinal No nausea, vomiting, or bowel changes
Genitourinary No dysuria, urgency, or incontinence
Musculoskeletal Reports dull lower back pain, no joint
swelling
Integumentary Denies having rashes, bruising, or
wounds
Neurological No numbness, tingling, or headaches
Psychiatric (screening tools: Ex:
PHQ-9, MMSE, GAD-7)
Feels stressed from work; no
depression or anxiety noted
Endocrine No polydipsia, polyuria, or heat/cold
intolerance
Hematologic/Lymphatic No easy bruising, bleeding, or swollen
nodes
ROS
(put N/A in sections
not completed day of
exam)
Allergic/Immunologic No known allergies or immune
disorders
Other Denies weight changes or urinary
symptoms
O: OBJECTIVE DATA
HR: 72 RR: 16 BP: 118/78 Temp: 98.4°F
SpO2%: 98% Ht: 5'6" Wt: 150 lbs BMI: 24.2
VITALS:
Age: 32 LMP: N/A PAIN:
Reports 4/10
dull lower
back pain
General Appearance Alert, well-nourished, in no acute
distress
Amanda Huber
109940000000053740
why is this NA?
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
Head Normocephalic, atraumatic
Eyes PERRLA, no conjunctival injection
ENT, Mouth Moist mucosa, no erythema or
lesions
Neck Supple, no lymphadenopathy or
thyromegaly
Cardiovascular/Peripheral Vascular Regular rate and rhythm, no
murmurs, pulses intact
Respiratory Clear to auscultation bilaterally, no
rales/wheezes
Breast N/A
Gastrointestinal Soft, non-tender, no
hepatosplenomegaly
Genitourinary Male
• External Exam N/A
• Internal Exam N/A
Genitourinary Female
• External Exam No GU complaints
• Internal Exam Deferred
Musculoskeletal Tender lumbar paraspinals, stiff
flexion, normal ROM, no swelling
Integumentary Skin intact, no lesions or rashes
Neurological Alert, oriented, normal strength
and sensation; negative straight-leg
raise
Psychiatric Appropriate affect; good insight and
judgment
Endocrine No signs of hormonal imbalance
Hematologic/Lymphatic No lymphadenopathy, no bruising
PHYSICAL
EXAM
(Pertinent data
related to
presenting
problem or
visit type. Put
N/A in sections
not completed
day of exam)
Allergic/Immunologic No signs of allergic reaction
Other N/A
A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS ICD-10 CODES
1. Low back pain (musculoskeletal) M54.5PRIORITIZE
DIAGNOSIS
2. Hypertension, controlled I10
Amanda Huber
109940000000053740
not objective data
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
3. Health maintenance (osteoporosis risk) Z79.899
VISIT CODES CPT BILLING CODES 99213 (Established patient, low-
moderate complexity)
POC TESTING None required. No tests today;
imaging if symptoms persist or
worsen
DIAGNOSTICS
TESTS REVIEWED N/A
P: PLAN
1. Diagnosis: Low back pain
Diagnostics Order: Consider lumbar spine X-ray if pain persists
beyond 4 weeks or worsens
Therapeutic: Naproxen 220mg PO BID PRN, continue stretching
and ergonomic adjustments at workstation
Education: Educated on posture, body mechanics, daily stretches;
avoid heavy lifting
Consultation/Collaboration: Refer to physical therapy if no
improvement in 4 weeks.
ACTIONS
2. Diagnosis: Hypertension
Diagnostics Order: Routine BP monitoring every 3–6 months;
annual CMP to monitor kidney function and electrolytes due to
lisinopril use.
Therapeutic: Continue lisinopril 10mg PO daily
Education: Reinforced adherence to low-sodium diet, encouraged
home BP monitoring
Consultation/Collaboration: No referral needed currently. May
consider referral to cardiology if BP control worsens or signs of
target organ damage arise.
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
3. Diagnosis: Health maintenance
Diagnostics Order: Schedule DEXA scan by age 40
Therapeutic: Encourage daily calcium (1000mg) and vitamin D
(800 IU) intake through diet or supplements to reduce osteoporosis
risk.
Education: Recommend eye exam within 6 months; discussed
importance of maintaining routine health screenings and dental
exams.
Consultation/Collaboration: May consider future referral to
ophthalmology if vision changes occur or if eye exam reveals
abnormalities
PREVENTITIVE
(Used for
comprehensive exams)
• Eye exam recommended
• DEXA scan by age 40
• Re-evaluation of back pain in 4 weeks
• Annual wellness visits scheduling
FOLLOW UP Follow-up in 4 weeks to reassess back pain and evaluate if PT or
imaging is needed
**SOAPNoteTemplate-Final28129.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/soapnotetemplate-final28129-docx-10305213)
**## annotated-SOAP20NOTE20UNIT204.docx.pdf**
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
S: SUBJECTIVE DATA
CC: "My lower back has been hurting for the past two weeks, especially after
long hours at my desk job. I’ve also noticed stiffness in the mornings."
HPI: • O: Gradual onset ~2 weeks ago
• L: Bilateral lower back
• D: Constant ache, worse by end of day
• C: Dull, achy pain
• A: Prolonged sitting, lifting heavy objects
• R: Heat, stretching, ibuprofen
• T: OTC meds, no PT
• S: 32F with lower back pain, likely musculoskeletal
PMH: • Hypertension (controlled, on lisinopril 10mg daily)
• Tonsillectomy at age 12
• No hospitalizations.
ALLERGIES NKDA
MEDICATIONS • Lisinopril 10mg PO daily (for HTN)
• Ibuprofen 400mg PO PRN (for pain)
SH • Occupation: Accountant (sedentary job)
• Non-smoker
• Occasional alcohol use
• Exercises 2x/week (yoga, walking)
• High work-related stress
• No drug use, low HIV risk
• Sexually active; no reported issues
• Moderate caffeine intake likely (desk job)
FH • Maternal: HTN diagnosed at 50, osteoporosis at 65
• Paternal: Type 2 diabetes diagnosed at 55
HEALTH
PROMOTION &
MAINTENANCE
• Immunizations: Flu (2023), COVID-19 booster (2023)
• Diet: Balanced, low sodium
• Exercise: Yoga and walking 2x/week
• Dental: Last exam 6 months ago
• Vision: Eye exam overdue (none in 2+ years)
• Plans for DEXA by age 40
Amanda Huber
109940000000053740
The assignment was to complete an annual wellness/new pt exam
Amanda Huber
109940000000053740
ask all age appropriate questions for screening for a 32 y/o female.
Amanda Huber
109940000000053740
Start with age and gender.
Amanda Huber
109940000000053740
Incorrect HPI for annual wellness/new pt
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
Constitutional No fever, chills, or fatigue
Head No headaches, trauma, or dizziness
Eyes No vision changes, eye pain, or
discharge
Ears, Nose, Mouth, Throat No congestion, sore throat, or ear
symptoms
Neck No stiffness or swelling
Cardiovascular/Peripheral
Vascular
No chest pain, palpitations, or edema
Respiratory Denies coughing, SOB, or wheezing
Breast No lumps or discharge reported
Gastrointestinal No nausea, vomiting, or bowel changes
Genitourinary No dysuria, urgency, or incontinence
Musculoskeletal Reports dull lower back pain, no joint
swelling
Integumentary Denies having rashes, bruising, or
wounds
Neurological No numbness, tingling, or headaches
Psychiatric (screening tools: Ex:
PHQ-9, MMSE, GAD-7)
Feels stressed from work; no
depression or anxiety noted
Endocrine No polydipsia, polyuria, or heat/cold
intolerance
Hematologic/Lymphatic No easy bruising, bleeding, or swollen
nodes
ROS
(put N/A in sections
not completed day of
exam)
Allergic/Immunologic No known allergies or immune
disorders
Other Denies weight changes or urinary
symptoms
O: OBJECTIVE DATA
HR: 72 RR: 16 BP: 118/78 Temp: 98.4°F
SpO2%: 98% Ht: 5'6" Wt: 150 lbs BMI: 24.2
VITALS:
Age: 32 LMP: N/A PAIN:
Reports 4/10
dull lower
back pain
General Appearance Alert, well-nourished, in no acute
distress
Amanda Huber
109940000000053740
why is this NA?
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
Head Normocephalic, atraumatic
Eyes PERRLA, no conjunctival injection
ENT, Mouth Moist mucosa, no erythema or
lesions
Neck Supple, no lymphadenopathy or
thyromegaly
Cardiovascular/Peripheral Vascular Regular rate and rhythm, no
murmurs, pulses intact
Respiratory Clear to auscultation bilaterally, no
rales/wheezes
Breast N/A
Gastrointestinal Soft, non-tender, no
hepatosplenomegaly
Genitourinary Male
• External Exam N/A
• Internal Exam N/A
Genitourinary Female
• External Exam No GU complaints
• Internal Exam Deferred
Musculoskeletal Tender lumbar paraspinals, stiff
flexion, normal ROM, no swelling
Integumentary Skin intact, no lesions or rashes
Neurological Alert, oriented, normal strength
and sensation; negative straight-leg
raise
Psychiatric Appropriate affect; good insight and
judgment
Endocrine No signs of hormonal imbalance
Hematologic/Lymphatic No lymphadenopathy, no bruising
PHYSICAL
EXAM
(Pertinent data
related to
presenting
problem or
visit type. Put
N/A in sections
not completed
day of exam)
Allergic/Immunologic No signs of allergic reaction
Other N/A
A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS ICD-10 CODES
1. Low back pain (musculoskeletal) M54.5PRIORITIZE
DIAGNOSIS
2. Hypertension, controlled I10
Amanda Huber
109940000000053740
not objective data
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
3. Health maintenance (osteoporosis risk) Z79.899
VISIT CODES CPT BILLING CODES 99213 (Established patient, low-
moderate complexity)
POC TESTING None required. No tests today;
imaging if symptoms persist or
worsen
DIAGNOSTICS
TESTS REVIEWED N/A
P: PLAN
1. Diagnosis: Low back pain
Diagnostics Order: Consider lumbar spine X-ray if pain persists
beyond 4 weeks or worsens
Therapeutic: Naproxen 220mg PO BID PRN, continue stretching
and ergonomic adjustments at workstation
Education: Educated on posture, body mechanics, daily stretches;
avoid heavy lifting
Consultation/Collaboration: Refer to physical therapy if no
improvement in 4 weeks.
ACTIONS
2. Diagnosis: Hypertension
Diagnostics Order: Routine BP monitoring every 3–6 months;
annual CMP to monitor kidney function and electrolytes due to
lisinopril use.
Therapeutic: Continue lisinopril 10mg PO daily
Education: Reinforced adherence to low-sodium diet, encouraged
home BP monitoring
Consultation/Collaboration: No referral needed currently. May
consider referral to cardiology if BP control worsens or signs of
target organ damage arise.
SOAP Note _______
NU___:_________
Herzing University
Name:_________________________
Typhon Encounter #: _____________________
Comprehensive:____Focused:____
3. Diagnosis: Health maintenance
Diagnostics Order: Schedule DEXA scan by age 40
Therapeutic: Encourage daily calcium (1000mg) and vitamin D
(800 IU) intake through diet or supplements to reduce osteoporosis
risk.
Education: Recommend eye exam within 6 months; discussed
importance of maintaining routine health screenings and dental
exams.
Consultation/Collaboration: May consider future referral to
ophthalmology if vision changes occur or if eye exam reveals
abnormalities
PREVENTITIVE
(Used for
comprehensive exams)
• Eye exam recommended
• DEXA scan by age 40
• Re-evaluation of back pain in 4 weeks
• Annual wellness visits scheduling
FOLLOW UP Follow-up in 4 weeks to reassess back pain and evaluate if PT or
imaging is needed
**SOAPNoteTemplate-Final28129.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/soapnotetemplate-final28129-docx-10305213)