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Nursing homework help

BM week 4 soap

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.
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, 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, 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
	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 Male
	· External Exam
	· Internal Exam
	Genitourinary Female
	· External Exam
	· Internal Exam
	Musculoskeletal
	Integumentary
	Neurological
	Psychiatric
	Endocrine
	Hematologic/Lymphatic
	Allergic/Immunologic
	Other

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.
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