MR soap wk 13: MR soap wk13 | Nursing

Clinical Requirement:

MR soap wk13 SNTemplate.docx SOAP Note _______ NU___:_________ Herzing University Name:_________________________ Typhon Encounter #: _____________________ 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. OBGYN History: This should include patient’s GPAL, past methods of deliveries, menopausal status, menstrual cycle history, LMP 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, heterosexual/bi/trans, form of contraception, 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-you don't need childhood vaccinations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) 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 (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 Pelvis 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 (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 Female · External Exam · Internal Exam Obstetric Musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematologic/Lymphatic 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: 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.) 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) Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling. 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: Diagnostics Order: Therapeutic: Education: Consultation/Collaboration: 3. Diagnosis: Diagnostics Order: Therapeutic: Education: Consultation/Collaboration: PREVENTITIVE (Used for comprehensive exams) Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver. FOLLOW UP