Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
R.B. 95-year-old, white male, currently living in a skilled nursing facility (SNF)
Chief complaint: “My urine is really red.”
HPI: On Wednesday (2 days ago) the patient was brought to your clinic by his son and complained that his urine appeared to be bright red in color. You ordered labs, urinalysis, culture, and sensitivity, and the results are below.
Allergies: Penicillin: Hives
Medications: Tamsulosin 0.4 mcg, 2 capsules daily, Aspirin 325 mg daily, Atorvastatin 10 mg 1 tablet daily, Donepezil 10 mg 1 tablet PO QHS, Metoprolol 25 mg 0.5 mg tablet every 12 hours, Acetaminophen 500 mg 1 tablet BID
Code status: DNR Regular diet, pureed texture, honey-thickened liquids
Vitals: BP 122/70, HR 66, Temp 98.0 F, Resp 18, Pulse ox 98% Weight:____ BMI:____
PMH: Cognitive communication deficit, pneumonitis due to inhalation of food and vomit, dysphagia, R-side hemiplegia and hemiparesis past ischemic CVA, moderate vascular dementia, malignant neoplasm of prostate, new-onset atrial fibrillation (12/2019), DVT on left lower extremity, gross hematuria
RBC 3.53 (L)
Hemoglobin 10.2 (L)
Microscopic Analysis, Urine, straight Cath
WBC UA 42 (H) (0-5/ HPF)
RBC, UA >900 (H) (0-5/HPF)
Epithelial cells, urine 2 (0-4 /HPF)
Hyaline casts, UA 0 (0-2 /LPF)
Appearance (Urine) Clear
Ketones, UA Trace
Specific gravity 1.020 (1.005-1.025)
Blood, UA Large
PH, Urine 7.0 (5.0-8.0)
C&S results were not available yet.
EPISODIC/FOCUSED SOAP NOTE TEMPLATE 2021 Dr. K
Patient Information: Initials, Age, Sex, Race
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 – or OLDCARTS.
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 Format Essay Example.
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. Please list in a bullet list, not a paragraph
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is i.e. angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
DO NOT LIST ALLERGIES IN TWO PLACES. POINTS TAKEN OFF FOR THIS.
PMHx: past major illnesses
PSH: and surgeries.
IMMUNIZATIONS: This is a separate item.
Depending on the CC, more info is sometimes needed. DO NOT STATE IMMUNIZATIONS “UP TO DATE” FOR ANY AGE. THIS IS USUALLY NEVER TRUE AND REALLY UNCLEAR AS TO WHAT THIS MEANS.
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. This should be no more than one brief paragraph REMEMBER TO INCLUDE HEALTH PROMOTION TEACHING AND EDUCATION FOR ALL PATIENTS, EVEN IF YOU ARE IN A CRITICAL CARE SETTING. THIS IS PART OF YOUR GRADING RUBRIC.
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. List in bullet points: I.E.
Mother: deceased age 79 MI
Father: alive & Well age 82
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. Use “denies” or “endorses”. Must be in interview format. You are interviewing the patient. Points taken off if the ROS sounds like a PE.
Note: if a body system is included in the CC and HPI – it must be included in the ROS and the PE. Please be mindful of this. It cannot be skipped if it is listed in the CC, HPI.
EXAMPLE OF COMPLETE ROS:
GENERAL: Orientation is often placed here. DO NOT PUT AA&O X3 OR 4. Points are taken off for this. For this course you must document what the patient is oriented to, i.e.:
Patient is alert and oriented to person, place, time and situation. (You do not need to put orientation in the PE in neuro unless you have not mentioned it elsewhere). The neuro PE should specify CN evaluation and Romberg -especially for stroke patients.
This Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae.
Ears, Nose, Throat denies hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: denies rash or itching.
CARDIOVASCULAR: denies chest pain, chest pressure or chest discomfort. denies palpitations or edema.
RESPIRATORY: denies shortness of breath, cough or sputum. (or – endorses productive cough with specks of blood)
GASTROINTESTINAL: denies anorexia, nausea, vomiting or diarrhea. denies abdominal pain or bloody stools. Denies hematochezia
GENITOURINARY: complains of burning on urination. Denies pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. denies change in bowel or bladder control.
MUSCULOSKELETAL: denies muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: denies anemia, or easy bruising.
LYMPHATICS: denies enlarged neck or armpit nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety. Denies suicidal ideations or attempts
ENDOCRINOLOGIC: denies reports of sweating, cold or heat intolerance. denies polyuria or polydipsia.
ALLERGIES: denies history of asthma, hives, eczema or rhinitis.
Start with vital signs: Temp, Pulse, Heart Rate, BP. O2 if acute care setting, weight and BMI mandatory.
It the heart rate is 99 and below – this is not tachy. If the heart rate is regular and 99 and below, this is NOT a “tachyarrhythmia”. Please grade murmurs if you identify one. Designate if your BMI is normal weight, overweight, obese, etc. This is important.
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.
IMPORTANT: Vital signs belong under PE not ROS. Do not put allergies on the soap note twice.
The neuro PE should evaluate the CN (list them – see the neuro exam doc in doc sharing)
The Muscle exam should note the muscle grading for each extremity starting at 5/5 to assess for weakness. If you are evaluating neuro and M/S together, title it that way. See form in doc sharing.
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 Format Essay Example.
DIFFERENTIAL DIAGNOSES (list a minimum of 3 differential diagnoses).
I highly recommend a pocketbook or app for differential diagnoses to help you with your soap notes.
Take your Geriatrics at Your Fingertips book with you to clinical.
I will post a list of DDx aps. In doc sharing. Please explore these as knowing DDx is very important and does take time to learn.
Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation of about one paragraph with evidence-based guidelines citations and references. Recommend using your textbooks and required readings as your first go-to references.
You are required to include at least three evidence-based peer-reviewed journal articles or evidenced based guidelines (but you can list as many as you wish) which relates to this case to support your diagnostics and differentials diagnoses.
You may use Up To Date once in a while but not as a general rule. Please use your textbook and required readings as your first choice for references. This will help you prepare for your knowledge checks.
Be sure to use correct APA 7th edition formatting. Journal articles or websites must be dated 5 years or sooner. Please use U.S. UK. Or Australian journal articles as a preference.
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