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Comprehensive SOAP Note

Comprehensive SOAP Note
 
Week SOAP Note
Subjective Data: History (this is what the patient tells you and your followup questions organized in a logical way)
Chief Complaint (CC): in a couple of words what is the patient being seen for today? (e.g., pelvic pain, vaginal discharge, nipple discharge, nausea and vomiting, etc.). This should be stated in the patient?s own words and not as a medical diagnosis. Be careful not to include more than one chief complaint (CC). If the CC is vaginal discharge with accompanying pelvic pain try to sort out if the pelvic pain is a separate CC or associated with the vaginal discharge.
Pearl: communication techniques of probing, reflection and summarization can assist patients with multiple symptoms to determine what is the most bothersome, or what symptom precipitated the visit to the clinic that day. (1 point)
History of Present Illness (HPI): Age, race, gender presents to the clinic with chief complaint of: essentially restating the chief complaint in a narrative rather than a list. This should not include student?s own opinion e.g., ?cough due to sinus drainage? *note this assignment is to describe a problem and not a well encounter i.e., NOT routine prenatal visit, discuss birth control options, well woman exam. Complete the HPI using the OLD CARTs format: (Onset, Location/radiation, Duration, Characteristics and/or associated symptoms, Aggravating factors, Relieving factors, Timing and Severity). These should all be relevant to your chief complaint.
Pearl: Documentation should be concise without use of phrases such as ?patient states, patient reports, complains of.? It?s understood that the patient is giving the history. If someone else is providing parts of the history, the student should document who and the relationship to the patient and whether the history seems reliable. Also document if an interpreter was used.
(7 points)
Current Medications: include only those medications the patient is currently taking including any OTC or herbal preparations include dosage, route, and frequency. Include PRN medication use if pertinent to the CC.
(2 points)
Allergies: include reaction i.e., hives
(2 points)
Past Medical History (PMH): these are medically diagnosed conditions (e.g., hypertension, hyperlipidemia, diabetes, migraine headaches) as well as illnesses (including childhood illnesses), hospitalizations if pertinent to the CC.
(2 points)
Past Surgical History (PSH): any previous surgeries requiring anesthesia (e.g., wisdom teeth extraction, bilateral tubal ligation, tonsils and adenoids). May include year of surgery or age at the time of surgery if known.
(2 points)
Personal/Social History: Tobacco use, alcohol use, drug use: record with detail (how much, how often) including recreational drug use and frequency. Include: marital status, dependents, occupation, living arrangements and other factors that may impact the treatment plan.
(2 points)
Immunizations: Last Tdp (date or age), an opportunity to identify need for updates or offer flu shot.
(2 points)
Menstrual History: Age at menarche, LMP: 3/14/14, (if you perform a pregnancy test as a part of your assessment i.e., urine hCG there must be a justification for this diagnostic test somewhere in your rationale/reflection) length of cycle: 28 days, duration: 3-5 days, characteristics of the flow: moderate flow, accompanying symptoms e.g., dysmenorrhea (include any regular problems with menses). (see p. 107 Schuiling & Likis)
(2 points)
GYN History: Include current method of contraception and sexual function.
(2 points)
Obstetric History: GTPAL (Gravida, Term, Preterm, Abortions, Living), include any surgical deliveries i.e., cesarean sections under PSH, include any problems with pregnancies e.g., gestational diabetes, gestational hypertension, newborn to NICU for 5 days with suspected sepsis, etc.
(2 points)
Family History: relevant immediate family medical history, note age of relative currently or at time of death, and whether alive or deceased currently. E.g., mother (alive and well) age 80 diagnosed with breast cancer age 45; father (deceased at age 70 ? pancreatic cancer). Two siblings both in their 30s with no significant medical problems.
(2 points)
Review of Systems (ROS): This is a systematic head to toe review of what the patient tells you when you ask them questions ONLY relevant to the chief complaint (e.g., I would not expect you would ask the patient about ear pain or ear canal discharge if the CC is vaginal discharge!) BUT it would be relevant to ask about fever, chills, nausea, vomiting, dyspareunia ? this is how you will be ruling in and ruling out potential differential diagnoses.
Pearl: review your physical assessment textbook for language to include relevant to each system. Novices often confuse subjective and objective findings.
General: any recent weight changes, weakness, fatigue or fever (you document denies or admits)
Skin: rashes, lumps, sores, itching, dryness or changes, etc.
HEENT:
? Head ?headache, dizziness, or syncope
? Ears ? Not assessed (this is appropriate to state when it is not relevant to the CC)
? Eyes ?problems or changes in vision
? Nose ? Not assessed
? Throat ? Not assessed
Neck:
Breasts:
Respiratory:
Cardiovascular:
Gastrointestinal ? as in the HPI admits intermittent abdominal pain (if you have already described this in the HPI you can refer back to it and state in was in the HPI), nausea or vomiting, constipation, diarrhea, bloody stools
Peripheral vascular:
Urinary: dysuria, urinary frequency, urgency
Genital:
Musculoskeletal:
Psychiatric:
Neurologic:
Hematopoietic: easy bruising (this may not be relevant to many of the CC commonly seen in women?s health but might be for some ? if not relevant you can state: not assessed)
Endocrine:
(20 points: include only relevant systems with appropriate medical terminology and organization, clarity, and correct spelling)
Pearl: avoid use of words that cannot be objectively measured e.g., mildly overweight ? define ?mildly?, no major complaints ? define ?major.? Scant, moderate, and heavy related to describing menstrual flow is acceptable because it has been defined.
Objective Data: (this is what information you gather from your physical examination (PE) of the patient). Follow a head to toe systematic, organized approach guided by the subjective data gathered from the CC, HPI, and ROS. You need only examine the systems that are relevant to the CC, HPI, and history. Do not use WNL or normal ? describe what you see, feel, and hear during your PE (refer to your physical assessment or course text for acceptable descriptors).
Vital Signs: T: 36.5 Celsius (oral), BP 111/75, P: 96, RR: 16, ht: 64 in. wt: 119 lbs. BMI: 22
(3 points)
General: no acute distress (you don?t need much more than this here ? you are generally evaluating whether or not your patient needs to go directly to the hospital or requires some kind of immediate attention). If you are concerned that the patient is inappropriately dressed for the weather or is under the influence of alcohol or drugs, etc. you may comment here with a full and detailed description justifying why you are calling an ambulance or the police or some kind of agency, but unless it is something like that you only need to evaluate if the patient can continue to be physically examined in an outpatient setting).
Skin:
HEENT: Not examined (It is likely with most women?s health CC that a complete examination of these systems will not be necessary ? it might be depending on your potential differential diagnoses but a thorough examination of the ears, eyes, nose, and throat must be justified by your CC and your formation of probable differential diagnoses). *Your preceptor might want you to examine all these systems for practicing skills but you do not include those in this academic SOAP note unless you can justify why you need the information. **Examining multiple systems just to increase your level of encounter in order to bill at a higher level is inappropriate and may be considered fraudulent!
Lymph nodes: Non-tender, no palpable masses
Neck: No masses, no thyromegaly (*do not document anything that you did not do ? if you didn?t perform an examination of the thyroid gland then do not document normal findings ? also fraudulent!)
Breasts: (please review the PE for a GYN visit in Schuiling & Likis p. 111-131).
Respiratory: CTAB (clear to auscultation bilaterally); No wheezes or crackles
Cardiovascular: RRR (regular rate and rhythm); normal S1, S2; no murmurs, rubs, or gallops
Abdominal:
? Abdomen soft, non-distended with no scars or striations
? No pulsatile masses, no abdominal bruits auscultated; positive bowel sounds
? Spleen not palpable, liver not palpable
? Tender to palpation in epigastric region and left upper quadrant; No reflex tenderness; No guarding; Murphy?s sign negative
Urinary: No suprapubic tenderness; no CVT (costovertebral tenderness)
Genital: (please review the PE for a GYN visit in Schuiling & Likis p. 111-131).
Pearl: Novices need guidance when to perform a full exam and what systems are relevant for particular chief complaints.
Rectal:
Neurologic: Not examined
Musculoskeletal: Not examined
(20 points: Is there a head to toe approach? Is the PE relevant to the CC and subjective findings? Are appropriate medical terms and descriptors used? Correct spelling? Are all elements included? Are there pertinent negatives?
Laboratory Data: This is where you would record any specimens you collected and sent to the lab i.e., urine, cervical secretions, blood, etc. If you collected a pap smear you would also need to justify why you collected a cervical cancer-screening specimen during a problem visit.
(1 point)
Diagnostic Tests: This is where you would record microscopy results (what are the criterion for a positive or negative wet prep of vaginal secretions?) or hemoccult results, etc.
(1 point)
Assessment: (this is where you list your probable differential diagnoses based on your subjective and objective data) * see SOAP grading rubric for details (minimum of three possible diagnoses from highest to lowest likelihood). You must provide support from your subjective and objective data for how you ruled in or ruled out each probable diagnosis and from evidence-based information from professional journal articles.
Differential Diagnoses: based on CC of vaginal discharge and subjective and objective findings the three most likely diagnoses in order of most likely to less likely are:
1. Bacterial vaginosis: This condition occurs ? (Reference). This is the primary diagnosis because ? (Reference)
2. Chlamydia: This condition occurs ? (Reference). This is less likely than BV because ? (Reference)
3. Trichomoniasis: This condition occurs ? (Reference). This is the least likely diagnosis because ? (Reference)
(12 points): 2 points for each correct differential and 2 points for each relevant professional reference
Plan:
1. Appropriate diagnostic tests ordered (supported from professional practice guidelines).
(1 point)
2. Medications written correctly (and supported from professional practice guidelines).
(1 point)
3. Patient education ? give examples of what kind of information you provided to the patient and in what form (i.e., written, verbal, video, etc).
(1 point)
4. Health promotion ? what information relevant to your diagnosis did you give the patient regarding health promotion?
(1 point)
5. Relevant follow-up and referrals documented ? when will the patient return to the clinic?
(1 point)
6. Document the level of encounter and the CPT code used for the primary diagnosis.
(1 point)
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