Episodic/Focused SOAP Note Template Examples

Episodic/Focused SOAP Note Template Examples

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: Episodic/Focused SOAP Note Template Examples.

BUY A PLAGIARISM-FREE PAPER HERE

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

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. Episodic/Focused SOAP Note Template Examples.

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. Episodic/Focused SOAP Note Template Examples.

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. Episodic/Focused SOAP Note Template Examples.

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) Episodic/Focused SOAP Note Template Examples.

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.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

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 6^th edition formatting.

Episodic/Focused SOAP Note Template – Episodic/Focused SOAP Note Template Examples 2

Patient Information:

L., 20, F, Caucasian

SUBJECTIVE.

CC: “I have been having sore throat for three days, and I also have decreased appetite, headache, and pain with swallowing.”

HPI: Ms. L is a 20-year-old female college student who presents with sore throat for three days, with additional decreased appetite, headache, and pain with swallowing. She recounts that similar “flu-like” symptoms recently affecting multiple students on campus. Ms. L also noted runny nose and a slight hoarseness in her voice but doesn’t sound congested. She took Tylenol and Chloraseptic lozenges, but did little for relief. Episodic/Focused SOAP Note Template Examples.

Location: throat

Onset: 3 days ago

Character: throat is sore

Associated signs and symptoms: decreased appetite, headache, and pain with swallowing.

Timing: constant

Exacerbating/ relieving factors: light bothers eyes, Tylenol makes it tolerable but not completely better.

Severity: 8/10 pain scale

Problem-Specific Questions:

Have you been coughing? Any drainage or phlegm? Is it productive, if so how much? What is the color of the phlegm?

Have you been running a fever or exhibiting chills?

Are you taking any medications for this? Are they helping?

Are you having any pain or pressure in your face, head, or sinuses? Have you recently had a head injury? Any nasal bleeding noted?

Do you smoke or have you been around anyone who smokes?

Do you experience gastroesophageal reflux or heartburn?

Does it hurt to swallow solids, liquids, or both?

Do you feel like something is stuck in your throat? Episodic/Focused SOAP Note Template Examples.

Do you cough or choke when swallowing?

Do you have any changes in your appetite? Did it start with the onset of your sore throat?

Any changes in your weight? Did you lose or gain weight?

What have you eaten in the last twenty-four hours?

Have you had any nausea or vomiting?

Current Medications: Multivitamins 1 tablet daily; and Blisovi Fe 1/20 1 tab daily

Allergies: Penicillin (Hives)

PMHx: No pertinent medical history reported, it is unremarkable. No recent hospitalizations reported in the past. Immunizations are current. Last tetanus shot was taken June 2010. Last flu shot was taken September 2016. Denies any history of accidents/injury or falls.

Soc Hx: Ms. L was born in Galveston, TX, and currently attends a community college at Houston Community College – Katy Campus. She attends classes Mon-Fri from 8am to 3pm. She works at daycare center on the weekends while in school, and during the week on Summer break. She is Single, and heterosexual. She is in a monogamous relationship with her boyfriend, and sexually active. She exercises 3x/week, and eats a diet consisting of meat/fish, vegetables, fruits, rice and beans. She drives a vehicle, and always put on her seatbelt. She is a social drinker, takes 1-2 glasses of wine every 2 weeks. Never smoked, and denies use of illicit/recreational drugs. Drinks green tea daily.

Fam Hx:

Maternal Grandmother: deceased at age 83 related to Stroke

Maternal Grandfather: deceased at age 98, no health conditions noted

Paternal Grandmother: deceased at age 38, post-partum hemorrhage

Paternal Grandfather: deceased at age 102 related to uncontrolled HTN

Mother: age 57, No health conditions reported Episodic/Focused SOAP Note Template Examples

Father: age 63, has Arthritis, and HTN

Siblings: She has 2 sisters age 18 and 16. Both are alive and well, no health conditions reported

Review of Systems:

GENERAL:  The patient is awake, alert, oriented and appears generally well. See HPI.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclera. No decreased hearing. No hearing loss, sneezing, or congestion. Has complaints of runny nose, sore throat, headaches, and hoarse voice.

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Respirations are regular and unlabored. No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. Complaints of decreased appetite

GENITOURINARY:  Denies burning in urination, never been pregnant. Menses are regular, last menstrual period, 05/28/2017.

NEUROLOGICAL:  No dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. Complains of headache that started with the onset of sore throat.

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness. Episodic/Focused SOAP Note Template Examples.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No history of splenectomy. Swollen nodes in the neck

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Allergic to PCN, gives her hives.

OBJECTIVE.

Physical exam: The patient is awake, alert, oriented and appears generally well. The patient is in no distress. Vital signs revealed a Ht. 5’10”, Wt. 150 lbs; BMI= 21.5; pulse of 96, respirations of 18, temperature of 101.6 and O2 saturation on room air of 98%. HEENT: Pupils are equal, round and reactive to light. There is no sinus tenderness. Ears are clear. Throat is slightly red with some swelling and exudate. Neck is supple with anterior cervical lymphadenopathy. Note runny nose and hoarse voice. Lungs are clear. Heart has regular rate and rhythm without murmur or gallop. Back showed no CVA tenderness. Abdomen is soft and non-tender. No organomegaly. Extremities: No edema or tenderness. Skin/Hair/Nails: Normal color for ethnicity and turgor without rash.

Diagnostic results: CBC and CMP ordered; throat swab was obtained and sent to the lab for rapid strep testing, rapid influenza diagnostic testing, and follow-up throat culture.

ASSESSMENT.

Differential Diagnoses

1. Influenza: Patient is exhibiting classic signs of sore throat, fever, headache, and nasal discharge (National Foundation for Infectious Diseases, 2016), with exposure to multiple infectious sources on her close-quartered college campus, this condition may be likely pending diagnostics.
2. Group A streptococcal pharyngitis: I would consider this due to her sore throat, but would need to visualize her mouth and throat to observe for possible erythematous and exudative tonsils and uvula, as well as other symptoms common to this diagnosis (Vincent et al, 2004). Episodic/Focused SOAP Note Template Examples.
3. Diphtheria: Common clinical manifestation includes low grade fever, sore throat, headache, malaise, and hoarseness (Centers for Disease Control and Prevention, 2016), very similar to my patient’s symptoms. However, this may be unlikely in United States as most people are vaccinated, though still prevalent in developing countries. In addition, Children under 5 and adults over 60 years old are particularly at risk for contracting the infection.
4. Epiglottitis: Because of her sore throat and vocal changes, this should be ruled out as it can advance to emergent airway obstruction, however, my suspicions would tell me that this is not probable as these patients often present in respiratory distress and it is a potentially life-threatening illness. This condition is historically a condition more common in children, but it is becoming more frequent in adults. It requires prompt diagnosis and treatment in anyone, but especially in children, who are more vulnerable to breathing complications (Marcin, 2017).
5. Epstein-Barr virus (EBV) infectious mononucleosis: Typically, these viruses spread most commonly through bodily fluids, especially saliva. Though classic signs of EBV is prolonged malaise, sore throat is a very prevalent sign, and the condition more common for those between ages 15-30 years, and close quarters being a common factor for transmission (Vincent et al, 2004), however, EBV should also be ruled out due to short time onset, and no enlarged spleen or liver noted.

PLAN.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Centers for Disease Control and Prevention (2016). About Diphtheria. Retrieved from

https://www.cdc.gov/diphtheria/about/index.html Episodic/Focused SOAP Note Template Examples

Marcin, J. (2017). Epiglottis. Retrieved from

http://www.healthline.com/health/epiglottitis#overview1

National Foundation for Infectious Diseases (2016). Influenza (Flu). Retrieved from

http://www.nfid.org/idinfo/influenza

Vincent, M., et al (2004). Pharyngitis. Retrieved from

http://www.aafp.org/afp/2004/0315/p1465.html Episodic/Focused SOAP Note Template Examples