Reference no: EM133981829

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. Maximize your scores with our expert assignment help - get help now!
HPI: Who is the historian? Is the historian reliable? History of Present Illness - 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]
Past medical history (PMH) - This should include illness/diagnosis, conditions, traumas, hospitalizations, and surgical history that is pertinent to the visit. Include dates if possible.
Reproductive history: GTPAL, STIs, prenatal care, LMP, contraceptive methods, sexual and menstrual history. Include dates if possible.
Allergies: State the offending medication/food and the reactions. Medications: Names, dosages, routes, frequency, and indications.
Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work, and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.
Family history: Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known.
Health Maintenance/Promotion - Required for all SOAP notes: Immunizations, exercise, diet, screening, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age-appropriate indicators, Healthy People 2030, and Centers for Disease Control and Prevention (CDC). This should reflect patient's current recommendations. Up to date on health maintenance/promotion will NOT be accepted. Requires references.
Review of systems (ROS) -
[Refer to your course modules and the Bickley E-text (Bates Guide) as a guide when conducting your ROS to make sure you have not missed any important symptoms,

particularly in areas that you have not already thoroughly explored while discussing the history of present illness.]
You would also want to include any pertinent negatives or positives that would help with your differential diagnosis. For acute episodic or follow-up visits (focused note) you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc. As opposed to a comprehensive visit which would address each system.
Perform either a focused or comprehensive ROS based on the visit type. General: May include if patient has had a fever, chills, fatigue, malaise, etc. Skin:
HEENT: head, eyes, ears, nose, and throat Neck:
Breast:
CV: cardiovascular Resp: respiratory GI: gastrointestinal GYN: gynecologic GU: genito-urinary
PV: peripheral vascular MSK: musculoskeletal Neuro: neurological Endo: endocrine Psych:
Objective (O):
Physical exam (PE) -
[Refer to your course modules and the Bickley E-text (Bates Guide) as a guide when determining what physical assessments, you want to include to further explore what you have learned from your subjective data collection]
Perform either a focused or comprehensive exam based on the visit type.

This area should confirm your findings related to the diagnosis. For acute episodic or follow-up visits (focused) you may be omitting certain areas such as GYN, Rectal, Abd, etc. While a comprehensive visit will exam each area.

Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory.

Gen: general statement of appearance if there is any acute distress. VS: vital signs, height and weight, BMI
Skin:
HEENT: head, eyes, ears, nose, and throat Neck:
Breast:
CV: cardiovascular Resp: respiratory GI: gastrointestinal GU: genito-urinary Gyn: gynecologic
PV: peripheral vascular MSK: musculoskeletal Neuro: neurological Endo: endocrine Psych:
Diagnostic Tests: This area is for tests that were completed during the patient's appointment that ruled the differential diagnosis in or out (e.g. - Rapid Strep Test, CXR, etc.).
Assessment (A):
This section should be a write-up utilizing your clinical decision-making with your diagnosis/diagnoses being supported by your ‘S' data set and the ‘O' data set. Pertinent positives and negatives must be found in the write-up. References required.
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.
Remember to include the appropriate ICD-10 code for each diagnosis.
A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e., HTN-well managed on medication).

Plan (P):
Your plan should be supported by evidence-based guidelines with appropriate citations utilizing APA formatting. Your evidence-based plan may be deviated from your preceptor's plan. Be sure to comment if there is a deviation in standard of care.

Document individual plans directly after each corresponding assessment (i.e., Diagnosis #1 found in the assessment should correlate with Plan #1). Address the following aspects (it should be separated out as listed below):
Diagnostics: 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 the name of the medication, dose, route, quantity, and number of refills for any new or refilled medications.
Educational: information clients need in order to address their health problems including the diagnosis itself, education on diagnostics, and therapies. 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.