SOAP Sample 1 - SOAP note documentation PDF

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Subjective Chief Complaint: 12 year old female with cold symptoms History of Present Illness: Patient has had 2-3 weeks of cold symptoms. She had had nasal congestion and runny nose for 2-3 weeks with green discharge. Her cough is productive, persistent and produces green sputum. She has had raw throat with cough without other concurrent sore throat. The cough is worse when lying down or when patient is active. She has tried cough drops and chloraseptic spray with little relief. She has had an intermittent headache that is generalized, is not associated with any precipitating events, is dull in nature is is relieved with Tylenol. She denies fever, vomiting, rash, decreased oral intake, shortness of breath. She has had difficulty sleeping due to presence of cough. Her sister was diagnosed with pneumonia 2 weeks previously and mother is concerned that patient has the same. She presents during thsi visit with her mother. Review of Systems: Growth and Development- Patient has been developing well and showing improvements with regular occupational and speech therapy due to her history of cerebral palsy. Constitutional- No fever. Mild fatigue. HEENT- Raw feeling throat with cough. Nasal congestion with runny nose producing green discharge. No irritation to eyes nor discharge. No ear pain or discharge. Pain to face with sensation of pressure. Respiratory- Productive strong cough with green phlegm. No difficulty breathing. Cough worsened when lying flat or with exertion. Gastrointestinal- No nausea, vomiting, diarrhea. Appetite mildly decreased though continues to have adequate oral intake. Neurological- Generalized headache without aura. No balance disturbance or other visual changes. Headache intermittent. History of cerebral palsy- no recent changes from baseline neurologic function since onset of symptoms. Skin- No rash or excessive dryness. Has had cold sores to lip previous week that self-resolved. Past Medical History: History of cerebral palsy and schizencephaly. Pt ambulatory and has difficulty with speech though her speech is comprehensible. She sees speech, physical and occupational therapists and has demonstrated improvement with services. She has required no surgical interventions.

SOAP NOTE 4- SINUSITIS 2 Immunizations: Up to date on immunizations though has not yet received seasonal influenza vaccine. MOC chooses to decline during this visit until feeling improved. Medications: 

Cetirizine HCl 10mg po qhs prn



Fluticasone Propionate 50mcg- 2 sprays daily per nostril- moderate compliance



Tylenol prn for headache- last dose in morning

Family History: Sister with recent diagnosis of pneumonia. No significant childhood illness in family including asthma or other respiratory illness. Allergies: No known drug or food allergies. Has seasonal allergies. Social History: Lives with mother and older sister. Performs well in school with IEP in place. Has friends gets along with other students. Sick contacts: Older sister with recent pneumonia diagnosis. No other known sick contacts.

Objective Physical Exam: Vital Signs: BP 104/60 HR 66 RR 20 O2 Sat 97% Temp 97.9 tympanic Wt 46.3 kg (height not checked/unable to determine BMI for this sick visit) General: Patient is in no acute distress. Interacts appropriately during exam and is active. HEENT: Head normocephalic and atraumatic. Conjunctiva clear bilaterally without discharge. Ear canals clear, tympanic membranes pearly grey with visible landmarks. Bullous lesion to right ear at approximately 11 o’clock without redness. Hearing grossly intact. Nose without external lesions, mucosa non-inflamed, septum and turbinates normal. Throat and oropharynx without erythema, exudates or lesions. Oral cavity: Mucous membranes moist without mucosal lesions. Sinuses: Tenderness upon palpation to maxillary and frontal sinuses. Cardiac: Regular rate and rhythm. S1 and S2 heard without murmur, gallop, rubs. Respiratory: Bilateral breath sounds clear and equal without rhonchi, rales, or wheezes. No increased work of breathing.

SOAP NOTE 4- SINUSITIS 3 Neck: Supple with full range of motion and without lymphadenopathy. Skin: No rash or excessive dryness. Capillary refill < 2 seconds. Neuro: Normal, symmetrical strength and tone. Answers questions appropriately. Speech clear and at baseline with mild slurring. Musculoskeletal: Tension to upper extremities without contractures. Steady gait with mild intoeing to left foot. Diagnostics: No diagnostics required at this time though pulse oximetry completed with vital signs. Assessment Differential Diagnosis: 1) Sinusitis (ICD-10 J01.9)- Likely due to the length of time of presenting symptoms lasting greater than 10 days, green nasal congestion, headache, cough and presence of sinus tenderness on physical exam. 2) Viral upper respiratory infection- Possible due to nasal congestion, cough, absence of fever, raw throat. Less likely due to prolonged period of symptom presence, lack of improvement over time, concurrent headache, and sinus tenderness. 3) Pneumonia- Possible due to persistent cough with green sputum and sister with similar symptoms and recent diagnosis of pneumonia. Less likely due to findings on physical exam with clear breath sounds to all fields, sinus tenderness, lack of fever on history. Assessment: Based upon the history of persistent illness that includes nasal discharge, green in color, and cough lasting greater than 10 days without improvement the diagnosis of sinusitis can be made. Further supporting this diagnosis are the physical findings that include sinus tenderness with palpation. Her allergic rhinitis that she has regularly is a predisposing factor for sinusitis (Wald, 2013). Plan The plan is to treat sinusitis with Augmentin XR dosed at 1 gram bid x 10 days. The Augmentin is dosed at 45 mg/kg/day (Wald et al, 2013). Either amoxicillin or Augmentin can be considered as first line treatments for acute bacterial sinusitis (Wald et al, 2013). The patient may take Tylenol or ibuprofen prn for continued headache. If patients demonstrates no improvement after 3 days of antibiotic therapy she should return to the clinic for reevaluation and consideration of alternative antibiotic administration. The use of antihistamines,

SOAP NOTE 4- SINUSITIS 4 decongestants and nasal steroids are not indicated at this time for symptom management. There are no further diagnostic studies are required at this time as this patient has no orbital or central nervous symptoms (Wald et al, 2013). She may find nasal irrigation to help remove nasal debris and improve nasal breathing if patient is able tolerate. Nasal saline spray is not shown to be beneficial in itself (Wald et al, 2013). Health Promotion/Risk Reduction: When antibiotic course has completed and patient is feeling improved she should return to clinic for annual influenza vaccine. Continuing to use Cetirizine for allergy maintenance to reduce allergic rhinitis. Patient should complete full course of antibiotics to adequately resolve acute sinusitis. Should she have multiple occurrences of sinusitis further evaluation will be required to potentially change management course. Other than routine vaccinations, another prevention method include utilizing sound hand hygiene. Again, if her symptoms of purulent nasal discharge, headache and sinus pain have not improved in 3 days she will need to return for reevaluation and consideration of alternative antibiotics. Collaboration with Preceptor: I evaluated this patient with Debbie Anne Moeller PNP. I first saw the patient independently, obtained a history and performed an assessment. After evaluation I suspected that this patient could be diagnosed with a sinus infection. Admittedly, I have had some reservation about the diagnosis of sinusitis. At times it has seen to be in the past like a vague diagnosis or an excuse to be able to given antibiotics to patients that are clearly looking for a prescription. This has made me dubious and I thought if I wrote this patient up and looked further into diagnosis criteria I would have a better understanding of sinusitis as a legitimate diagnosis. It was helpful to see a patient that appeared as a more classic example of sinusitis. I was able to look at the recommendations with Debbie Anne to determine antibiotic course that is appropriate in this scenario. Coding 1. History: Comprehensive 1. HPI- Extended due to use of more than 4 elements including: location, onset, duration, aggravating factors, therapies initiated 2. ROS- Detailed due to fewer than 10 systems covered in ROS including: constitutional, HEENT, neck, skin, and neuro 3. Past medical, family, social history areas- Complete because of review of all three of these area

SOAP NOTE 4- SINUSITIS 5 b. Examination: Detailed 1. Using 97 guidelines determined that less than 8 organ systems were examined b. Medical Decision Making: Low Complexity 1. Number of Diagnoses and/or Management Options- 3 points assigned because this is a new problem that required no additional work up 2. Amount and/or Complexity of Data- 0 points because no tests were performed and no old records necessitated review 3. Risk of Complicaations and/or Morbidity or Mortality- Low as this patient has “acute uncomplicated illness” For an established patient in an outpatient setting with a comprehensive history, a detailed exam and straightforward decision making this patient will be coded as a 99214.

SOAP NOTE 4- SINUSITIS 6 References Wald, E.R., Applegate, K.E., Bordley, Darrow, C.D., Glode, M.P., Marcy, S.M., Nelson, C.E., R.M., Shaikh, N., Smith, M.J., Williams, P.V., & Weinberg, S.T. (2013). diagnosis and management of acute bacterial sinusitis 10.1542/peds.2013-1071

Rosenfeld,

Clinical practice guideline for the

in children aged 1 to 18 years. Pediatrics. doi:...