Episodic SOAP Note Template PDF

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Summary

FNP Pediatric Episodic soap note template. Use to create standard episodic soap notes...

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EPISODIC SOAP Note Template

Student’s Name:

Shauntara Brown

Date: 8/2/2021

Patient / Client initials: VR

Age: 34

Gender: Female

Ethnicity: Hispanic

SUBJECTIVE DATA Chief Complaint (CC) History of Present Illness (HPI)

“I am relocating to a new house and while moving boxes last week I think I got something in my eyes”. “First my right eye was red and itching and now my left eye is red and itchy with discharge”.

The patient VR is a 34 y/o Hispanic female who presents to the clinic with a chief complaint of bilateral eye pain that she describes as red and itchy. She reports a gradual onset that started 3-4 days ago after she was moving some boxes. She recalls rubbing her eyes while moving. She reports the severity to be mild and the quality of pain to be irritating. She reports thick yellow discharge from her left eye. The patient states when she wakes up it is hard to open her eye as the discharge is crusted over. She has used warm compresses with a washcloth without relief.

Past Medical History (PMH)

Anemia in 1991 Motor Vehicle Accident 1991

Past Surgical

Back surgery in 1991 Pelvic surgery from trauma 1991

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History (PSH) OB/GYN history (if applicab le)

Tibia fracture surgery 1991

Last menstrual cycle July 15, 2021 Gravida 0/Para 0 Last Pap January 2021 normal Performs routine breast exams Last mammogram: N/A History of STI: None

Immunizati on status

All immunizations up to date, no reactions. Flu vaccine 2020, Covid-19 Vaccine 2021

Medications

OTC Multivitamin daily

Allergies

No known Allergies

Family History (FH)

No Family history on file

Psychosocia l or Social History (SH) Nutritional Screening if applicable Advanced Directives if applicable

Denies the use of alcohol, tobacco, smokeless tobacco products and illicit drugs

Review of System s (ROS) Constitutio

Employed and married

Not Applicable

Not Applicable

Denies weight change, fever, chills, night sweats, fatigue, and/or malaise

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nal Skin Eyes, Ears, NoseThroat /Mouth

Cardiovascu lar

Denies skin lesions, pruritis, or hair changes.

ENT/Mouth: No Hearing Changes, No Ear Pain, No Nasal Congestion, No Sinus Pain, No Hoarseness, No sore throat, No Rhinorrhea, No Swallowing Difficulty Eyes: Positive for redness and itching bilateral eyes. Positive for purulent yellow drainage left eye.

No Chest Pain, No SOB, No PND, No Dyspnea on Exertion, No Orthopnea, No Claudication, No Edema, No Palpitations

Respiratory Denies having a cough, sputum, wheezing, or dyspnea

Gastrointes tinal

Reproductiv e / Genitalia / Genitourina ry

Denies N/V/D, denies constipation, pain, heartburn, anorexia, dysphagia, hematochezia, melena, flatulence, or jaundice

Denies dysmenorrhea, dyspareunia, dysuria, urinary frequency, hematuria, or urinary incontinence

Denies arthralgias, myalgias, joint swelling or stiffness. Denies back or neck pain, denies injury Musculoske letal Neurologica l

Denies syncope, paresthesia or numbness

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Psychiatric Denies anxiety/panic, depression, insomnia, personality changes, delusions, rumination, Denies SI/HI/AH/VH, social issues, memory changes, violence/abuse Hx., eating concerns Hematologi c /Lympha tic Endocrine

Physical Exam

Denies bruising, bleeding, transfusions history, lymphadenopathy

Denies polyuria, Polydipsia, and temperature intolerance

OBJECTIVE DATA Pleasant & cooperative Hispanic female. Engaged in conversation and maintains eye contact throughout interview and examination. Vital signs stable, in no acute distress.

General/ Constitutional Vital Signs

Temp: 98.6, HR: 72, BP: 121/71, RR: 18; O2 sat 100% on RA Height: 63 inches, Weight: 135 pounds, BMI: 23.9 (Normal)

Skin

Warm, soft, smooth, with good turgor throughout. No rashes, erythema, lesions, or changes in pigmentation

HEENT

Head: Normocephalic/atraumatic. Symmetric. Normal hair distribution and pattern. Eyes: PERRLA. EOMI. Right eye redness and conjunctival hyperemia noted. Small amount of drainage noted. No edema. Left eye redness and conjunctival hyperemia noted. moderate amount of purulent drainage noted. No edema. TMs intact bilaterally. Cone of light noted. Nose: Nares patent bilaterally. Septum midline, nasal mucosa pink; no edema or drainage. Throat: Oral mucosa pink and moist. Tongue midline. Pharynx without redness or exudate. Good dentition.

Neck

Supple. Trachea midline. No thyromegaly. No lymphadenopathy.

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Respiratory

Lungs clear bilaterally. No rales, rhonchi, or wheezing. No distress noted.

Cardiovascular

RRR. Normal S1 and S2 auscultated. No murmurs. No S3 or S4 auscultated.

Breast Assessment deffered Abdomen

Soft, nontender. Active bowel sounds.

Female Genitourinary/ GYN

Assessment deferred.

Rectal

Assessment deferred.

Musculoskelet al (including frailty evaluation if applicable)

Normal gait. No obvious deformities. Normal range of motion in extremities.

Neurological

Alert and oriented x4. No gross focal, motor or sensory deficits. Full neurological assessment deferred.

Diagnostic Informati on

LAB/DIAGNOSTIC TESTS/EKG: Visual acuity with Snellen and Rosenbaum 20/20 corrected (glasses) No further lab work or diagnostics required at this time.

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ASSESSMENT: DIFFERENTIAL DIAGNOSES AND SUPPORTING DATA 3-5 differential diagnoses for each presenting problem

Data in your findings that support this diagnosis

Mucopurulent conjunctivitis, bilateral H10.023

Bilateral eye purulent drainage, redness and itch, matted eyelids, ROS and HPI

Data in your findings that rule out this diagnosis

Citation of evidence for accepting or rejecting the diagnosis

Burning, redness, tears, and mucopurulent discharge are all symptoms of acute conjunctivitis. Patients frequently remark that when they wake up, their eyelids are matted together. (Jacobs et al., 2020)

Allergic Conjunctivitis (H10.45)

The patient has no other symptoms indicating allergies

Symptoms of allergic conjunctivitis include bilateral eye redness, itching, watery discharge; typically have a history of allergies and may present with associated allergic rhinitis. (Jacobs et al., 2020)

Viral Conjunctivitis (B30.9)

The patient did not report any current or previous URI symptoms.

Redness, watery or mucous discharge, and a burning/sandy/gritty feeling in one eye are typical symptoms of viral conjunctivitis, which generally spreads to the other eye within 24-48 hours. It is possible to report a recent URI or contact with a sick person. Because it is usually caused by the same virus that causes the common cold, individuals may have conjunctivitis symptoms alone or as part of a larger illness. (Jacobs et al., 2020)

No edema noted to eyelids

Symptoms include foreign body or burning sensation, excessive tearing, itching, redness of the eye, red and swollen eyelids, photophobia, dandruff-like scales on the eyelashes, or crusting on the eyelashes on awakening. It may be caused by bacteria, scalp dandruff (seborrheic dermatitis), or problems with the meibomian glands that lead to inflammation of the

Blepharitis (H01.003)

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7 Ron and Kathy Assaf College of Nursing Hybrid Activities and Assignments eyelids and the above symptoms. (Buttaro et al., 2017)

Final ICD 10 diagnosis codes for the current visit ICD 10 Code H10.023

Corresponding Diagnosis

Mucopurulent conjunctivitis, bilateral H10.023

PLAN: TREATMENT PLAN (For graded SOAP note submissions, include rationale for all components of treatment plan and support with citations from peer-reviewed information)

Treatments: Pharmacological

Treatments: NonPharmacological Patient Education

Moxifloxacin (Vigamox) 0.5% ophthalmic solution: instill one drop in right and left eye three times a day for seven days

Use cool or cold sterile wipes or a cotton cloth to clean the eyelids. Place cool or warm washcloths over your eyes; do not share or discard washcloths. Rinse with water after washing your face and eyelashes with a mild baby shampoo.

Within 24-48 hours, redness, inflammation, and ocular discharge should start to fade. Even if your symptoms go away sooner, complete the entire course of treatment (7 days). If possible, stay at home until the discharge from the eye has stopped. Wearing contact lenses is not recommended until the

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treatment course is completed and the symptoms have subsided. If you're using a disposable contact lens, discard it and replace it. Eye makeup, particularly mascara, should be discarded. Keep your hands away from your eyes and don't rub or touch them. The best strategy to control the spread of conjunctivitis and prevent recurrence is to practice proper hygiene. Avoid touching your eyes with your hands; Wash your hands properly and often; Change your towel, washcloth, and pillowcase frequently; do not exchange towels or handkerchiefs Avoid sharing eye makeup and replace it on a regular basis. - Carefully handle and clean contact lenses.

Disposition

Instructed the patient to schedule a follow up appointment in one week if symptoms have not improved or worsened. The patient was given the opportunity to ask questions about the diagnosis, recommendation, and treatment plan during the visit. The patient expressed complete understanding of the aforementioned at the conclusion of the visit. The patient was informed of all findings. The patient was informed about the clinical impression. W ritten instructions for discharge were provided in detail. The patient consents to the discharge plan, which includes a follow-up appointment if symptoms worsen or do not improve within one week. The patient is aware that any change in condition, worsening symptoms or any other concerns should notify the office immediately or go to the nearest emergency room. At the time of discharge the patient is nontoxic appearing, non-focal, in no apparent distress with stable vital signs. The anticipated course to resolution of symptoms was discussed.

Next office visit scheduled, identify the plan for follow-up, note expectations for further treatment.

CPT Billing Codes Reflected in the Treatment Plan

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CPT Code

Corresponding Diagnosis

1. Office visit E/M code

2. 3. 4. 5. Point of care testing (urine dipstick, wet mount, x rays, etc.) and resulted IN OFFICE, and any procedures done in office

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Patient Name _____________________________________

Date ___________________

_______________________________________________________________________________________________

Rx

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Refill NR 1 2 3 4 5 Signature ____________________________________________________________

References

Buttaro, T. M., Trybulski, J. A., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Evaluation management of eye disorders. In Primary care: A collaborative practice (5th ed., pp. 326–358). essay, Elsevier.

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Jacobs, D. (2020, August). Patient education: Conjunctivitis (pink eye) (Beyond the basics). Uptodate. https://www.uptodate.com/contents/conjunctivitis-pink-eye-beyond-the-basics....