Focused SOAP Note #2

FOCUSED SOAP NOTE GUIDE and RUBRIC (ATTACHED IS THE RUBRIC).

Do NOT reuse SOAP note from previous practicum.

Patient and diagnosis in any of the SOAP notes cannot be the same as Case Study Presentation.

SOAP notes should discuss adult patients, age 16 and older, who present with a chief complaint. Please indicate, next to the selected patient, a case number that correlates with one of your EXXAT patients seen in clinical setting. Pre-op patients or pre-procedure patients, who present for clearance, and who don’t have a chief complaint, do not meet the criteria.

The SOAP note should mimic clinical documentation in the practicum setting. The documentation should be accurate, clear, well organized and utilizes medical terminology.

SUBJECTIVE (20 points)

CC – the reason for the visit as stated in the patient’s own words

Example: I have been coughing frequently for 5 days.

HPI (History of Present Illness)

1-Describe the chief complaint in a chronological manner and include symptom dimensions, and chronological narrative of patients complains.

a.First sentence should include patient’s identifying data, including age, gender, race if clinically relevant, and pertinent past medical history. If the information is obtained from other sources, always identify source

b.Use PQRST or OLDCARTS mnemonic to guide you in obtaining pertinent information.

c.Incorporate elements of the PMHx, FHx and SHx relevant to the patients chief complaint, and elaborate on them to add pertinent information.

d.Include pertinent positives and negatives based on relevant portions of the R.O.S.

e.HPI should also present the context for the differential diagnoses.

2- If the patient has a PMHx, relevant to the the chief complaint, it should be described and elaborated on in a separate small paragraph

For example:

Mr. X is a 54 year old man with PMHx of asthma, who presents with persistent cough X 5 days, worse at night, productive of small amount of whitish phlegm etc. (continue with all pertinent negatives and pertinent positives that help you reach your primary diagnosis and help you rule out your differential diagnoses).

Asthma was diagnosed 5 years ago, triggered by exercise and cold weather, and treated with inhalers as needed. Reports that he last used inhalers one month ago. ( Elaborate on Asthma in a separate paragraph in HPI, since Asthma is part of PMHx tha is relevant to cc)

PMH (Pertinent past medical history)

PSHx (Pertinent surgical history)

Pertinent Family History, Social History and other subjective data if relevant to the patients presenting problem and diagnosis.

Medications – Current medications (list with daily dosages).

Allergies: describe the nature of the adverse reaction

ROS (Pertinent review of systems) a system- based list of questions that help uncover symptoms not otherwise mentioned by the patient. In a focused SOAP note, only include systems pertinent to the presenting problem and/or diagnosis. Follow the proper order of the different systems.

OBJECTIVE (15 points)

Vital signs

PE focused physical exam finding limited to systems pertinent to the problem

Same systems reviewed in ROS should be addressed in PE. Follow the proper order of the different systems in PE.

Laboratory or diagnostic data, if perfomed before this visit, and if applicable, belong in this section and after physical exam, with the appropriate date.

Laboratory or diagnostic data during this visit belong under Plan, not here.

ASSESSMENT (Problem List) with ICD-10 Codes (20 points)

This section documents the synthesis of subjective and objective evidence to arrive at a diagnosis. This is the assessment of the patients status through analysis of the problem, possible interaction of the problems, and changes or progress in the status of the problems.

The assessment could also contain the possible causes of the patients problem, especially if the patient is experiencing an illness.

If the patient had made a visit before, it should also contain the progress which had been made since the last visit as well as the overall progress towards fully treating the symptoms, based on the perspective of the main physician.

List the problem list (diagnosis/es) in order of importance.

1.Primary diagnosis (most likely)

2.Relevant chronic medical condition (s)

Example:

#1 Primary Diagnosis acute viral bronchitis (J20.9) –

Mr. X is a 54 yr old man with HTN presents with frequent cough x 5 days, worse at night with small amount whitish sputum, denies SOB, fever and chills, and with a normal lung exam. Symptoms are most likely consistent with acute viral bronchitis.

#2 Asthma (I10), controlled. No recent use of inhalers and no wheezing on exam (ex. of how you address the patient’s chronic relevant medical condition in Assessment)

PLAN (20 points)

This has to be evidence- based, using the latest clinical guidelines. This should include pharmacologic, non-pharmacologic, education, referrals, and follow-up when applicable. The plan should be personalized and appropriate for the patient. The plan should address all the problems in Assessment, new and relevant chronic.

Example:

#1 acute viral bronchitis (J20.9)

• supportive care, no antibiotic therapy
• OTC Dextromethorphan/guaifenesin 10ml Q4hrs
• Follow up in 1 week if no improvement or if condition worsens, a CXR can be done to r/o pneumonia.

#2 Asthma, controlled (ex. of how you include chronic conditions in your plan)

continue inhalers as needed

DIFFERENTIAL DIAGNOSES (See Rubric) include ICD-10 Codes and Evidence- Based Rationale (20 points)

• Identify 3 considered differential diagnoses. DDx are related to the chief complaint. Include the Most LIKELY diagnosis/diagnoses in your differential. Order your differential to reflect the most likely or more serious first. Provide a brief rationale for each differential diagnosis (3-4 sentences) – rationale should provide data that support your differential diagnoses presentation, PE finding and/or lab/diagnostic test results that make it similar to the diagnosis and explain the difference between the differential and working diagnoses and/or the laboratory/diagnostic tests that would make the diagnosis. Explain what makes it likely and what makes it less likely. Cite.
• Briefly discuss the rationale of the plan. Provide clinical guidelines used to support the plan, cite.

HERE IS THE PATIENT THE NOTE IS BASED ON WITH ID# 260130190453

Pt is here today with c/o urinary symptoms.

This is a 29-year-old woman who presents with a 2-day history of dysuria, urinary frequency, and urgency. She reports a burning sensation with urination and suprapubic discomfort. She denies flank pain, fever, chills, nausea, vomiting, vaginal discharge, or hematuria. No recent history of UTIs. No concern for STI at this time.

Medications: None

PE:

Vitals: Temp 98.6F BP 116/74 HR 82 RR 16 SpO2 99% RA

General: Well appearing female, in no acute distress

Cardiac: Regular rate and rhythm. No murmurs

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, non-distended. Mild suprapubic tenderness. No CVA tenderness bilaterally

Impression: Acute uncomplicated urinary tract infection N39.0

Plan: Nitrofurantoin (Macrobid) 100 mg, 1 capsule PO BID x 5 days, Urine culture obtained and sent; will adjust antibiotics if indicated based on results, Increase oral fluids, Educated patient on UTI prevention measures, Advised to return to office or call for fever, flank pain, worsening symptoms, or no improvement, F/U 1 week with lab revieww.