Episodic SOAP Note Template Rx-1 PDF

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Summary

These notes are for nurse practitioner pediatric test good luck on your test...

Description

EPISODIC SOAP Note Template

Student’s Name:

Date:

Patient / Client initials:

Age:

Gender: Comment

Male

Female

Ethnicity:

SUBJECTIVE DATA Chief Complaint (CC) In patient’s own words. Identity and reliability of informant if patient is not informant.

History of Present Illness (HPI) For EACH component of the Chief Complaint: Must include Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Timing, and Severity (OLDCARTS). Include pertinent positives from the review of systems as they relate to the HPI.

Past Medical History (PMH)

Current/Past medical problems with date of onset

Past Surgical History (PSH) Surgeries and Procedures with date performed and outcome

OB/GYN history (if applicable)

Gravida/Para. LMP. Last PAP w/ results. Last Mammogram w/ results. History of STI.

Immunization status Age specific immunizations, list and describe any history of reactions

Medications Current medications: include medication name, dose, route, frequency, duration, and reason for taking

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Allergies

Medications, Foods, Environmental, Latex and how allergy is manifested

Family History (FH) 2nd degree blood relatives (grandparents, parents, siblings, children): Age, living/deceased, medical problem.

Psychosocial or Social History (SH) Pt. profile (sexual orientation, marital status, children), lifestyle risk factors (illicit drug use, alcohol use, smoking/pack year, exercise) , ehistory, education, religion, cultural history, support system, stressors, driving

Nutritional Screening if applicable Advanced Directives if applicable

Report findings from a nutritional screening tool you used to interview patient

Report patient wishes and name/relationship of DPOAHC

Episodic visits should include ROS and Physical Exam only for body systems relevant to the complaint

Review of Systems (ROS) Constitutional

General statement by the patient (reported symptoms that do not fit one system but often affect

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overall status)

Skin

Eyes, Ears, Nose Throat/Mouth Cardiovascular

Respiratory

Gastrointestinal

Reproductive / Genitalia / Genitourinary Musculoskeletal Neurological

Psychiatric

Endocrine

Hematologic /Lymphatic Immune function / dysfunction

OBJECTIVE DATA Physical Exam General/ Consitutional

General description of patient including age, gender, nutritional status, habitus, attention to grooming, state of cooperativeness/demeanor, overall picture of wellness/distress

Vital Signs

Temperature, Pulses (apical and radial), Respirations, BP (Postural PRN), Ht, Wt, BMI

Skin

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HEENT

Neck

Respiratory

Cardiovascular

Breast

Abdomen

Female Genitourinary/ GYN

Male Genitourinary/ Prostate Rectal

Musculoskeletal (including frailty evaluation if applicable) Neurological

(Mental Status, Cranial nerves, Motor, Cerebellum, Motor, Cerebellum, Sensory, Reflexes)

Psychiatric including mental health/ substance use screening tools and interpretation of results (Document findings from depression screen, Mini-mental status exam, CAGE, etc.)

Diagnostic Information 4

Results of diagnostic testing conducted at the time of the visit OR previously done and being used to support the diagnosis and management plan for the current visit

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

Data in your findings that rule out this diagnosis

Data in your findings that support this diagnosis

Citation of evidence for accepting or rejecting the diagnosis

Final ICD 10 diagnosis codes for the current visit ICD 10 Code

Corresponding Diagnosis

1. Primary diagnosis for the visit

2. 3. 4. 5. Additional diagnoses for the visit AND active problems from the medical history that may contribute to the diagnosis and plan for the current visit (ie DMII or HTN may impact management even if the visit is not related to these diagnoses)

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

Additional

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diagnostic tests needed Treatments: Pharmacologica l Treatments: NonPharmacologica l Patient Education

Consultations recommended with rationale Disposition

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

CPT Billing Codes Reflected in the Treatment Plan 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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Nova Southeastern University Medical Clinic Florida

Patient Name _____________________________________

Date ___________________

Rx

Refill NR 1 2 3 4 5 Signature ____________________________________________________________

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