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Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b) Pertinent positives and negatives must be documented for each relevant system.

c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4) Assessment (___10pts.): Encounter paragraph and diagnoses should be clearly listed and worded appropriately including ICD10 codes.

5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

6) Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

Comments:

Total Score: ____________ Instructor: __________________________________

Guidelines for Focused SOAP Notes

· Label each section of the SOAP note (each body part and system).

· Do not use unnecessary words or complete sentences.

· Use Standard Abbreviations

S: SUBJECTIVE DATA (information the patient/caregiver tells you).

Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis, physician-recommended return(s) for this patient visit. The patient’s own words should be in quotes.

History of present illness (HPI): a chronological description of the development of the patient’s chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last patient encounter.

Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-appropriate immunization status.

Family History (FH): Update significant medical information about the patient’s family (parents, siblings, and children). Include specific diseases related to problems identified in CC, HPI or ROS.

Social History(SH): An age-appropriate review of significant activities that may include information such as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of education and sexual history.

Review of Systems (ROS). There are 14 systems for review. List positive findings and pertinent negatives in systems directly related to the systems identified in the CC and symptoms which have occurred since last visit; (1) constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13) hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE findings section.

0: OBJECTIVE DATA (information you observe, assessment findings, lab results).

Sufficient physical exam should be performed to evaluate areas suggested by the history and patient’s progress since last visit. Document specific abnormal and relevant negative findings. Abnormal or unexpected findings should be described. You should include only the information which was provided in the case study, do not include additional data.

Record observations for the following systems if applicable to this patient encounter (there are 12 possible systems for examination): Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lymphatic/immunologic/lab testing. The focused PE should only include systems for which you have been given data.

NOTE: Cardiovascular and Respiratory systems should be assessed on every patient regardless of the chief complaint.

Testing Results: Results of any diagnostic or lab testing ordered during that patient visit.

A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code)

List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.

Remember: Your subjective and objective data should support your diagnoses and your therapeutic plan.

Do not write that a diagnosis is to be “ruled out” rather state the working definitions of each differential or primary diagnosis (es).

For each diagnoses provide a cited rationale for choosing this diagnosis. This rationale includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the focused PE findings and tests results that support the dx. Include the interpretation of all lab data given in the case study and explain how those results support your chosen diagnosis.

P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include an EBP citation.

1. Medications write out the prescription including dispensing information and provide EBP to support ordering each medication. Be sure to include both prescription and OTC medications.

2. Additional diagnostic tests include EBP citations to support ordering additional tests

3. Education this is part of the chart and should be brief, this is not a patient education sheet and needs to have a reference.

4. Referrals include citations to support a referral

5. Follow up. Patient follow-up should be specified with time or circumstances of return. You must provide a reference for your decision on when to follow up.

SOAP Note PATIENT INFORMATION:

NAME: MG AGE: 66 SEX: Female SOURCE: Patient ALLERGIES: -NKA. CURRENT MEDICATIONS: -Lisinopril 5 mg PO daily PMHX: -Essential Hypertension SURGICAL HISTORY: -Unremarkable FAMHX: -Mother died (MI). Father died (Lung CA) SOCHX: Hispanic, social drinker, no history of psychiatric diseases, denies using illicit drugs, retired, 60-pack-year smoking history, consumes coffee 3-4 times per day. Lives with her husband, well grooming, has 3 sons who visit her often. Patient admits poor compliance with regular treatment.

SUBJECTIVE:

CC: “I’ve been feeling shortness and cough”

HPI: 66-year-old woman with a 60-pack-year smoking history and diagnosis of hypertension made 12 years ago, who comes to the office c/o 3 months of mild shortness of breath and dry cough. Until recently, she was able to walk the four blocks to her local grocery store without shortness of breath; however, now she is able to walk only one block before having to stop and rest. She has been waking from sleep with difficulty breathing and feels uncomfortable lying flat in bed. Patient states poor compliance taking her routine blood pressure medication.

ROS:

CONSTITUTIONAL: Patient denies significant weakness, fever, chills, diminished appetite, hasn’t notice evident weight changes. NEUROLOGIC: Denies tremors, headache, seizures, gait imbalance, tics or numbness in lower extremities, no visual disturbances or speech problems, no dizziness. HEENT: Denies difficulty swallowing, hoarseness, odontalgia, sore throat, hearing loss, ear pain or pruritus. RESPIRATORY: Patient states dry cough when having shortness of breath after walks about one block, which improves after stop and rest for few minutes. Denies increased respiratory secretions or fever. CARDIOVASCULAR: Until recently, she was able to walk the four blocks to her local grocery store without shortness of breath; however, now she is able to walk only one block before having to stop and rest. She has been waking from sleep with difficulty breathing and feels uncomfortable lying flat in bed. Patient states poor compliance taking her routine blood pressure medication. Denies chest pain or sustained palpitations. GASTROINTESTINAL: Denies regurgitation, heartburn, diarrhea, no abdominal pain, fats are well

tolerated, no history of abdominal surgery, also denies rectal bleeding and constipation. GENITOURINARY: Patient is bowel and bladder continent, denies polyuria, dysuria, cloudy or foul urine recently, denies evident blood in urine, denies history of ulcers, vesicles, genital discharge or pain. Denies breast nodules or abnormal findings in the past. SKIN: Denies unexpected skin lesions, skin rash or pruritus. MUSCULOSKELETAL: Denies muscle weakness or spasms, muscle or joint pain.

OBJECTIVE:

CONSTITUTIONAL: Blood pressure is 154/92; heart rate is 90/min; respiration rate is 18/min; O2 saturation is 94% on room air; and temperature is 98F, weight 164 pounds, height 5’5”, BMI 27.3 NEUROLOGIC: AAOx3, no gait disturbances, no central or peripheral focal neurological deficit, muscle tone, grip strength and gross sensation, intact. HEENT: PERRLA, EOMs intact, pearly and non-bulging tympanic membrane bilaterally, no redness or discharge noted in the ear canal, no JVD, no enlarged lymph nodes or neck mass. No erythema noted on oropharynx. No white/yellow plaques or ulcers noted on palate, uvula or tonsils. CARDIOVASCULAR: Her physical examination is notable for crackles at the lung bases. There is no evidence of hepatosplenomegaly or jugular venous distention. An EKG performed at the office shows normal sinus rhythm, no ST deviations, no pathological T or Q waves. R wave voltage may indicate underlying LVH. No murmurs, there is no chest wall tenderness, no collateral circulation, no peripheral edema, carotid, apical, radial femoral and pedal pulses present and strong, no carotid murmur bilaterally. RESPIRATORY: Her physical examination is notable for crackles at the lung bases, she is speaking in full sentences, has a midline trachea, and has no dullness to percussion, or increased tactile fremitus over the lung fields. There is mild diminished breath sounds bilaterally. GASTROINTESTINAL: Oral cavity with no lesions suggestive of malignancy, wet oral mucosa, abdomen soft, non-tender, non-distended, no organomegaly, no hernias, bowel sounds present in all four quadrants. GENITOURINARY: Genital exam deferred today. Percussion to CV regions elicits no pain. MUSCULOSKELETAL: Joints without swelling, increased temperature or redness. INTEGUMENTARY: Intact skin, warm, pink, no alopecia or desquamative lesions on lower extremities. No signs of infection, no neurovascular pathological findings on feet.

ASSESSMENT:

1. HEART FAILURE, UNSPECIFIED (ICD10 I50.9): Heart failure (HF) is the condition resulting from inability of the heart to fill and/or pump blood sufficiently to meet tissue metabolic needs. Alternatively, HF may occur when adequate cardiac output can be achieved only at the expense of elevated filling pressures. It is the principal complication of heart disease. HF is the preferred term over congestive heart failure because patients are not always congested (fluid overloaded). HF may involve the left heart, the right heart, or be biventricular. The New York Heart Association (NYHA) classification is a subjective grading scale used for classifying patients with HF: NYHA I: asymptomatic; NYHA II: symptomatic with moderate exertion; NYHA III: symptomatic with mild exertion and may limit activities of daily living; NYHA IV: symptomatic at rest. For acute HF, see “Heart Failure, Acutely Decompensated.”

2. ESSENTIAL (PRIMARY) HYPERTENSION (I10). 3. OVERWEIGHT (ICD10 E66.3).

DIFFERENTIAL DIAGNOSIS:

-COPD: No evidence of barrel chest, minimal wheezing, accessory muscle use, pursed lip breathing, cyanosis, although there is mild diminished breath sounds bilaterally.

-Cardiac ischemia: No history of chest pain during shortness of breath episodes, no syncope, no tachyarrhythmias, EKG shows no evidence of current/old CAD, patient isn’t diabetic.

-Anemia: No paleness, no resting tachycardia, no generalized weakness, patient is well nourished, States good appetite.

-Hyperthyroidism: No resting tachycardia, no enlarged thyroid gland, no heat intolerance, no anxiety or tremors, no sweating, overweight patient.

PLAN:

This patient is experiencing symptoms of heart failure (NYHA stage II) due to uncontrolled hypertension as a must likely etiology, she recognizes poor compliance with regular antihypertensive medication, cough doesn’t seem to be associated with the use of Lisinopril. Today we’ll order a set of laboratory studies, chest x ray, and echocardiogram, also lifestyle modifications with emphasis in smoking cessation and cardiac diet as well as regular exercising. Lisinopril dose will be increased. No diuretic treatment will take place today since there isn’t evidence of fluid overload.

CBC ESR Lipid Panel Comprehensive Metabolic Panel Urinalysis Β-Type Natriuretic Peptide (BNP) Doppler Echocardiography Radiologic Exam, Chest Single View Tobacco Use Cessation

Pharmacologic treatment : -Lisinopril 10 mg PO daily for hypertension (new).

Non-Pharmacologic treatment / Education:

What are the causes? Heart failure is most often caused by coronary artery disease or a heart attack. It may also be caused by problems with the heart’s valves. You may have heart failure because you had an infection in your heart muscle. It may be due to high blood pressure or an abnormal heart rhythm. Sleep apnea or high blood sugar may also cause your heart not to work as well as it should. These causes result in a weak or damaged heart muscle. When your heart is weak or damaged, you may have heart failure. What can make this more likely to happen? You are more likely to have heart failure if you are older or are someone who smokes. Black men have more heart failure. Having high blood pressure or being overweight can also raise your chances of having heart failure. So can drinking too much beer, wine, and mixed drinks (alcohol). People with long-term diseases like emphysema are more likely to have problems with their heart.

What are the main signs? Breathing problems like: Shortness of breath Cough that won’t go away Wheezing Extra fluid that causes: Swelling of feet, ankles, legs, or belly Gaining weight and you don’t know why Need to pass urine more often Problems sleeping like: Need to sleep sitting up or on many pillows Waking up often during sleep times Feeling tired, weak, or have no energy General signs like: Increased heart rate Belly pain Loss of appetite and nausea Feeling lightheaded or dizzy Confusion and impaired thinking

How does the doctor diagnose this health problem? The doctor will take your history and will do an exam. The doctor will listen to your heart and lungs, and may also feel your belly for liver swelling. The doctor will check your feet, ankles, and legs for swelling. The doctor may order: Lab tests Chest x-ray Electrocardiogram (ECG or EKG) Echocardiogram Exercise stress test Radioactive imaging. This is a radionuclide scan. Dye injected into the heart’s arteries. This is coronary angiography.

How does the doctor treat this health problem? Your doctor will treat you to help your heart work better. The doctor will also work to control your signs. Since other health problems may cause or make heart failure worse, it is important to also treat these. Your doctor may suggest: Diet and lifestyle changes to slow down progress of the illness Drugs to help your heart work better, get rid of the extra fluid, and control your heart rate and blood pressure Exercise and cardiac rehab Bypass surgery or a heart stent to open blocked vessels to the muscle of your heart Devices like a heart pump Heart transplant

What lifestyle changes are needed? Limit how much beer, wine, and mixed drinks (alcohol) you drink. Limit the salt in your diet.

Lose weight if you are overweight. Stop smoking. Remain active. Talk with your doctor about the right amount of activity for you. In severe cases, limit how much fluid you drink. Be careful that you take your drugs each day as ordered by your doctor. If you cannot afford them, they may be able to help you. Do not stop your drugs if you have side effects. Talk to your doctor about them. Check your weight each morning and write down your weight in a notebook. This will tell you if you are building up too much fluid. Weigh in the morning after you have passed urine. Weigh yourself with clothes on or off, but do it the same way each day. Make sure your scale is on a hard surface, not on carpet. Your doctor will tell you when you should call based on how much weight you gain in a day or over a week. Take your notebook to your doctor on your next visit.

What drugs may be needed? Often patients will need to take more than one drug. Together, they will help the heart work as well as it can. Do not take any other prescription drugs, over-the-counter (OTC) drugs, herbals, or diet aids without asking your doctor. The doctor may order drugs to: Help relax blood vessels. This makes it easier for the heart to work and may also lower your blood pressure. These are ACE inhibitors and ARBs. Slow down the heart rate so that it doesn’t have to work as hard. These are beta blockers. Help the heart beat stronger and better. Get rid of extra salt and water in the body. These are water pills or diuretics.

What changes to diet are needed? Ask your doctor what kind of diet is best for you. The doctor may tell you to limit your salt and fat or how much fluid you drink. The DASH diet may be helpful. The DASH diet helps to lower blood pressure. This diet includes lots of fruits, vegetables, low-fat dairy foods, and foods that are low in saturated fat, total fat, and cholesterol. Using the DASH diet with a low salt diet may lower blood pressure even more.

What can be done to prevent this health problem? Keep a healthy weight. Keep blood pressure, cholesterol, and high blood sugar under control. Stop smoking. Do not use nicotine gum or patches unless your doctor says it is OK. Exercise regularly. Talk to your doctor about which exercise program is best for you.

When do I need to call the doctor? Activate the emergency medical system right away if you have signs of a heart attack. Call 911 in the United States or Canada. The sooner treatment begins, the better your chances for recovery. Call for emergency help right away if you have: Signs of heart attack: Chest pain Trouble breathing Fast heartbeat Feeling dizzy Call your doctor if you have: Problems with breathing. These include an increase in shortness of breath, wheezing, needing to sleep while sitting up to breathe, or other breathing troubles.

Problems with swelling and weight gain. These include gaining more than 2 to 3 pounds (0.9 to 1.35 kg) in a day or 5 pounds (2.25 kg) in a week; more swelling in your feet, ankles or legs; passing more or less urine than normal; or passing dark urine. Feelings of being very tired or weak Pain in your arm(s), neck, jaw, belly, or back Cough that does not go away or coughing up pink or white foamy mucus A pounding heart that is racing very fast or skipping beats You are not feeling better in 2 to 3 days or you are feeling worse

Helpful tips Carry a list of all the drugs you take with you at all times. Include any over-the-counter (OTC) drugs or herbals. If you have an implanted pacemaker or defibrillator, carry the card for the device with you at all times.

Follow-ups/Referrals: -Return in 3 days to review lab studies and treatment effectiveness. -None referral will take place today.

References:

Codina Leik, T. M. (2018). Family Nurse Practitioner Certification Intensive Review. New York: Springer.

Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62(16):e147–e239.

Yancy C, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017;136(6):e137–e161.

Yancy C, Jessup M, Bozkurt B, et al. 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2016;68(13):1476–1488.

Curtis AB, Worley SJ, Adamson PB, et al. Biventricular pacing for atrioventricular block and systolic dysfunction. N Engl J Med. 2013;368(17):1585–1593.

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