Assignment Prompt & Instructions
soap may 12
– Identify a friend, peer, or family member you can
– a year ago
**files (1)**
– ## Soap.docx
**## Soap.docx**
| | |
| — | — |
| **SOAP Note _______**<br>NU___:_________<br>Herzing University | **Name:_________________________**<br>Typhon Encounter #: _____________________<br>**Comprehensive:____Focused:____** |
| | | |
| — | — | — |
| S: SUBJECTIVE DATA |
| CC: | What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased. |
| HPI: | Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary] |
| PMH: | This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. |
| ALLERGIES | State the offending medication/food and the reactions. |
| MEDICATIONS | Names, dosages, and routes of administration along with indication of use. |
| SH | Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. |
| FH | Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known. |
| HEALTH PROMOTION & MAINTENANCE | **Required for all SOAP notes:** Immunizations, exercise, diet, etc. Remember to use the <br>[United States Clinical Preventative Services Task Force (USPSTF)](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams. |
| ROS <br>(put N/A in sections not completed day of exam) | Constitutional | |
| | Head | |
| | Eyes | |
| | Ears, Nose, Mouth, Throat | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |
| | | | | |
| — | — | — | — | — |
| O: OBJECTIVE DATA |
| VITALS: | HR: | RR: | BP: | Temp: |
| | SpO2%: | Ht: | Wt: | BMI: |
| | Age: | LMP: | PAIN: | |
| PHYSICAL EXAM <br> <br>(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam) | General Appearance | |
| | Head | |
| | Eyes | |
| | ENT, Mouth | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary Male |
| | · External Exam | |
| | · Internal Exam | |
| | Genitourinary Female |
| | · External Exam | |
| | · Internal Exam | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |
| | | |
| — | — | — |
| A: ASSESSMENT AND DIAGNOSIS |
| | DIAGNOSIS | ICD-10 CODES |
| PRIORITIZE DIAGNOSIS | 1. | |
| | 2. | |
| | 3. | |
| | | | |
| — | — | — | — |
| VISIT CODES | | CPT BILLING CODES | |
| DIAGNOSTICS | | POC TESTING | |
| | | TESTS REVIEWED | |
| | | |
| — | — | — |
| P: PLAN |
| ACTIONS | 1. | Diagnosis: <br>Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)<br>Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)<br>Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.<br>Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning. |
| | 2. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
| | 3. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
| PREVENTITIVE <br> <br>(Used for comprehensive exams) | | Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver. |
| FOLLOW UP | | |
**## Soap.docx**
| | |
| — | — |
| **SOAP Note _______**<br>NU___:_________<br>Herzing University | **Name:_________________________**<br>Typhon Encounter #: _____________________<br>**Comprehensive:____Focused:____** |
| | | |
| — | — | — |
| S: SUBJECTIVE DATA |
| CC: | What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased. |
| HPI: | Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary] |
| PMH: | This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. |
| ALLERGIES | State the offending medication/food and the reactions. |
| MEDICATIONS | Names, dosages, and routes of administration along with indication of use. |
| SH | Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. |
| FH | Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known. |
| HEALTH PROMOTION & MAINTENANCE | **Required for all SOAP notes:** Immunizations, exercise, diet, etc. Remember to use the <br>[United States Clinical Preventative Services Task Force (USPSTF)](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams. |
| ROS <br>(put N/A in sections not completed day of exam) | Constitutional | |
| | Head | |
| | Eyes | |
| | Ears, Nose, Mouth, Throat | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |
| | | | | |
| — | — | — | — | — |
| O: OBJECTIVE DATA |
| VITALS: | HR: | RR: | BP: | Temp: |
| | SpO2%: | Ht: | Wt: | BMI: |
| | Age: | LMP: | PAIN: | |
| PHYSICAL EXAM <br> <br>(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam) | General Appearance | |
| | Head | |
| | Eyes | |
| | ENT, Mouth | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary Male |
| | · External Exam | |
| | · Internal Exam | |
| | Genitourinary Female |
| | · External Exam | |
| | · Internal Exam | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |
| | | |
| — | — | — |
| A: ASSESSMENT AND DIAGNOSIS |
| | DIAGNOSIS | ICD-10 CODES |
| PRIORITIZE DIAGNOSIS | 1. | |
| | 2. | |
| | 3. | |
| | | | |
| — | — | — | — |
| VISIT CODES | | CPT BILLING CODES | |
| DIAGNOSTICS | | POC TESTING | |
| | | TESTS REVIEWED | |
| | | |
| — | — | — |
| P: PLAN |
| ACTIONS | 1. | Diagnosis: <br>Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)<br>Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)<br>Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.<br>Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning. |
| | 2. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
| | 3. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
| PREVENTITIVE <br> <br>(Used for comprehensive exams) | | Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver. |
| FOLLOW UP | | |