Crohn’s Disease

VERY IMPORTANT:

” all other systems are revised and negative ” is not acceptable in a SOAP note. you need to document all systems.

Below are examples of the RO and PE:

ROS

-CONSTITUTIONAL: Denies weight loss, fever and chills.

HEENT: Denies changes in vision and hearing.

RESPIRATORY: Denies SOB and cough.

CV: Denies palpitations and Chest pain.

GI: Denies abdominal pain, nausea, vomiting and diarrhea.

GU: Denies dysuria and urinary frequency.

MSK: Denies myalgia and joint pain.

SKIN: Denies rash and pruritus.

NEUROLOGICAL: Denies headache and syncope.

PSYCHIATRIC: Denies recent changes in mood. Denies anxiety and depression

PHYSICAL EXAMINATION

-GENERAL: Alert and oriented x 3. No acute distress. Well-nourished.

EYES: Normal vision, PERRLA, Anicteric.

-HENT: Moist mucous membranes. No scleral icterus. No cervical lymphadenopathy.

LUNGS: Clear to auscultation bilaterally. No accessory muscle use.

CARDIOVASCULAR: Regular rate and rhythm. No murmur. No JVD.

ABDOMEN: Soft, non-tender and non-distended. No palpable masses.

-MSK: No asymmetry or muscle atrophy. Full range of motion (ROM) of all joints

-SKIN: No rashes or lesions. Warm. Good skin turgor

-NEUROLOGIC: No focal neurological deficits. CN II-XII grossly intact, but not individually tested.

PSYCHIATRIC: Cooperative. Appropriate mood and affect.

SOAP Notes

SOAP notes must meet the required quality standards for students in the integration rotation.

The Chief Complaint (CC) and Review of Systems (ROS) should match.

Do NOT document objective data in the ROS; this section is only for subjective data.

The Physical Examination (PE) of the affected system should be properly documented.

Primary or final diagnosis

At least 3 differential diagnoses must be documented and explained thoroughly in each SOAP note.

When recording prescribed medications, please include complete information:

Name of medication, Strength, Dose, Route, Duration of treatment

The screening tests and education sections must be properly documented.

References must be recorded in each SOAP note.

**Please add labs results and all studies reports.