The goal of this assignment is to introduce the SOAP note format. A SOAP template has been provided below for your use. You will be given a scenario to select and need to identify the Subjective components in the narrative. You will take that data that you’ve been given, and you will enter the data in the appropriate area on the Soap note, you will want to abbreviate the content and complete a Review of Systems.
There is limited objective data (so those objective date areas of the SOAP will be blank).
You will then contemplate the information that you’ve been given, and from this information, you will create a diagnosis and a plan (80% of your visit diagnosis will come from your history). You will complete the SOAP note sections with an ICD 10, Diagnosis with Differentials, Plan, Patho, and rationale.
What you will see is that you can do the majority of your Diagnosis with an excellent history. Focus your diagnoses on what you “see.” Often as a provider, you start your diagnoses based on a physical finding or a complaint, and then you will fine-tune it based on your examination or other tests. For example, a patient presents with a cough based on history; you may then determine the patient is having respiratory distress through observation, you will then continue to fine-tune your diagnosis to Wheezing with your examination, and then once you have finished you have narrowed it down to Mild intermittent Asthma with exacerbation. This process will start with a vague diagnosis and become more specific as you gather more specific data.
Instructions
First, read the Mixed-up Soap Note Scenario. Mixed up SOAP Note Scenario- 15yr old
Mixed up soap note 15 year old.docx
Actions
Second, complete the SOAP NOTE Blank Template attached to the scenario, using only the information provided.
SOAP Template.docx
Actions
Decide what is pertinent and then place the components in the correct sections of subjective and objective components.
Use appropriate abbreviations and concise terminology if appropriate.
If you are lacking pertinent information supply the questions that you would ask the patient (pretend you are completing the visit, how would you phrase the questions)
Considerations
What type of history will you obtain for this visit? (The SOAP note Template is a Template used in multiple courses, some of the boxes may not be applicable to your assignment)
What additional history would you obtain from the family that is significant to the situation? Use italics or colored font to add questions in the SOAP. Present the Questions as you would pose them to the patient.
Practice using clinical reasoning and list possible diagnoses for the scenario. based on the subjective information provided
The Following must be included in your SOAP submission
Subjective Content
Identifying Information
Chief Complaint
HPI
Family, Personal/Social
Current Health
PHM
Review of Systems
Primary Medical Diagnosis
ICD 10 code (you may do a simple google search)
Provide pathophysiology for each diagnosis (1 paragraph)
The rationale for each diagnosis
Plan for each diagnosis
Pertinent positives for each diagnosis (list 2)
Pertinent negatives for each diagnosis (list 2)
3-5 Differential diagnosis
ICD 10 code (you may do a simple google search)
Provide pathophysiology for each diagnosis (1 paragraph)
The rationale for each diagnosis
Plan for each diagnosis
Pertinent positives for each diagnosis (list 2)
Pertinent negatives for each diagnosis (list 2)
Other
Health maintenance/risk profile (if appropriate for your visit type)
Reference List (you are researching your diagnosis you should have at least 2 references)
APA format