Episodic Focused Soap Note

Episodic-Focused SOAP Note Template

Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

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Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
A.
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
P.
Include additional laboratory and diagnostic tests, consults, therapeutic modalities, health promotion patient education as well as disposition/follow up instructions as they pertain to your patients’ assessment

References
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.

Assignment 2: Assessing, Diagnosing, and Treating Patients With HEENT Conditions
Most everyone has at some point experienced minor HEENT conditions, such as a head cold or seasonal allergies, and symptoms, such as a runny nose, watery eyes, or a sore throat. While they are relatively minor and short-lived, they nevertheless impair many of the simple pleasures so many enjoy.
HEENT symptoms can represent a wide variety of issues, some of which suggest problems that extend well beyond their temporary impact on life’s simple pleasures. HEENT conditions can result in dangerous respiratory impairment or be symptoms of life-threatening conditions or disease.
For this Assignment, your instructor will assign a case study, which will give you the opportunity to practice assessing, diagnosing, and treating patients with HEENT conditions.

To Prepare:
1. Consider how to assess, diagnose, and treat patients with conditions of the head, eyes, ears, nose, and throat.
2. Review the case study provided by your Instructor. Based on the provided patient information, think about the health history you would need to collect from the patient.
3. Consider what physical exams and diagnostic tests would be appropriate in order to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis.
4. Identify three to five possible conditions that may be considered in a differential diagnosis for the patient.
5. Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
6. Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with HEENT conditions.

Assignment Requirement: Please use at least 3 scholar sources:
-Based on the case Study, Write an explanation of the primary diagnosis, as well as 3 differential diagnoses, for the patient in the case study you selected. Describe the role of the patient history and physical exam played in the diagnosis. Then, suggest potential treatment options based on your patient diagnosis (Treatment would includes the dosage/day and how many days). You can make up normal findings in the other areas. For example, CV-Pt denies chest pain or palpitations. In the physical exam section, document what you would find in a patient who complains of nosebleed. You can also make up PMH, SH, FH.
Please use the SOAP Note Template.

Please see also the “Sample” for the format of this assignment

Case Study:
-A mother brings in her 11-year-old son, Branch, because he has had a nosebleed. She is concerned about it because they have been applying pressure by pinching it and the nosebleed won’t stop. He has no history of nosebleeds. He has no significant medical history and no known allergies. He is on no medications. Mom and Branch deny trauma to the nose. He says he just woke up with a nosebleed and it won’t stop. He tells you that the left side is the side that is bleeding.
-Vital signs: BP 110/70 P 84 R 14 T 97.8 oral Pulse ox 99%
You recognize that simple pressure is not going to stop the nosebleed so you know that you will not have to intervene.

Questions need to be answered after completing the SOAP:

1. Prior to any type of procedure, you have the mother sign an informed consent for a procedures. What are the three major areas you must discuss when doing any type of procedure?
2. Nosebleeds can be divided into three groups. What are they?
3. 90% of nosebleeds fall into which group?
4. Name 4 indications for intervention by a provider for a nosebleed.
5. You place Branch on the exam table at approximately 45 degrees. You drape him appropriately. You have him blow his nose gently to remove clots. You then inspect the right side to familiarize yourself with his anatomy. You then inspect the left side using a nasal speculum. When using the nasal speculum, it is important to use it ______________ (HORIZONTALLY/VERTICALLY).
6. Why is it important to use the nasal speculum a certain way?

7. You note that the bleeding is coming from an area on the septum. You know that the next step is to apply a vasoconstrictive solution to the nose. What are two ways you can deliver the vasoconstrictive solution?
8. You note that the area that is the source of the bleeding is about 3 mm in diameter. You make the decision to use a silver nitrate stick. How long should you apply pressure with the stick?

9. Why it is it important not to use the silver nitrate for over that time frame?
10. After hemostasis is obtained, what are three types of treatment methods that can be used to protect the cauterization site?

11. If that had not stopped the bleeding and you had to make the decision to use a nasal sponge or nasal tampon, the sponge/tampon should be coated in _____________ and left in place for __________ hours.
12. After putting in the nasal sponge/tampon, approximately 2 ml of ________ or _______ should be dripped onto the tip to help the sponge expand.
13. After placing the nasal sponge/tampon, the patient should be closely monitored for 3-5 minutes. Why is that?
14. After the close monitoring, the patient should be kept in observation status for ______ minutes.
15. If a sponge/tampon is used, it is not necessary to use antibiotics.
16. If it is necessary to pack the nose, it may be advisable to give the patient a narcotic or sedative medication (unless a contraindication exists). Why?
17. Name 5 complications of the above procedures.
18. After the procedure, you tell the pt and his mother that he can take acetaminophen for any pain/discomfort. Why is it important not to have him take ibuprofen?
19. What is the leading cause of nosebleeds in adolescents?
20. What CPT code would you use for the above procedure?
21. What is the definition of the above code? For more information on Episodic Focused Soap Note visit this: https://en.wikipedia.org/wiki/SOAP_note

Episodic Focused Soap Note

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