SOAP NOTE
· Create a neuro-related CC. Create an ID, CC, HPI, ROS, V/S, physical findings, and assessment with at least 3 differential diagnoses, a final diagnosis, and treatment plan in a full SOAP note format. Use a neuro related CC that a patient would present with in a primary care setting (i.e. no emergency room or ICU type complaints). Examples: regular headaches, migraines, dizziness, dementia or memory loss, weakness, neuropathy, etc..
· Include at least two references for your diagnostic and treatment plan. They should be recent (in the last 5-10 years) and peer reviewed. Use APA title page, citation, and references. Ensure the treatment plan includes all components (diagnostic plan, therapeutic plan, education plan, and follow up).
· The ROS and physical exam in your document should be written up as they would be for a problem focused visit.
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· The neurological part of the physical exam write up should be a comprehensive write up, including everything you assessed in your recording. (I have added the one I will be assessing in the physical exam)
SOAP NOTE TEMPLATE
Subjective
ID: Paragraph form Include info such as initials, DOB and age, race, gender, whether the patient is a reliable source, and how they came to the clinic (alone/ accompanied by spouse, etc.) Some clinicians write a statement about their overall reliability as a historian/recorder of their information. To protect confidentiality, please use a made up DOB and initials.
CC: ALWAYS in patient’s own words. Use quotations.
HPI Write this out in Paragraph form , not bullets. Include all the elements of HPI.
“OLDCARTS”
Onset/timing
Location
Duration
Context/Setting & Characteristics (i.e. Quality)
Aggravating factors and Associated Symptoms
Relieving factors
Treatments tried/Modifying Factors
Severity
VS: Temp, BP, RR, HR
Example:
HPI : Jillian X, a 63 year old white Jewish female, is here for her annual wellness visit. She states that she is in overall average physical health and her last physical was mo/d/2018. Her last mammogram was x/xx/20xx and last pap smear was x/xx/20xx, both normal. Jillian has had most normal health screenings as advised, and her last cholesterol levels were done on x/x/20xx and normal. She admits she has never had a colonoscopy. Her current complaint list includes a runny nose and ear pain that began 3 weeks ago (8/19/2019) and occurs intermittently. She has used aloe vera homemade remedy and feels relieved from her remedy within in 20 min. The symptoms were not so severe as to cause her to seek treatment (those she report ear ache as 8-9/10) but she felt she was able to handle them at home. She has no other complaints at this time.
PMH
Medical Problem list:(diabetes, asthma, HTN, etc)
Surgeries and hospitalizations (include mo/year ):
Immunizations: (including annual flu vaccine, for older people PNA and shingles vaccine)
Allergies: (food, drug, environmental, and the reaction)
Medications (Rx and OTC, supplements and herbal)
Family History (use abbreviations – MGM, FGM, FGF, etc. ask about siblings and children. Include ages of parents and relatives at the age they passed away)
Chemicals: (including ETOH, tobacco/nicotine, drugs)
Diet/exercise/caffeine (general diet – vegetarian? Red meat? Fast food and how often), exercise- what form, how long and often)
Sexual/Reproductive History LMP, contraception and protection, birth history (can also go up in PMH/surgeries if c-section), STI history, partners, orientation)
Social History :
Occupation,marital/relationship/military status & current living situation: This should be obvious. For living situation, make sure to include whether house, apartment, hotel, shelter, etc.
Spiritual/Social Supports: (indicate religious affiliation if they have one, major belief systems, community or other social support)
Safety: Helmets, seatbelts, texting/drinking and driving, does the patient own guns? Keep them locked? Own a pool on property? Any history of domestic violence/partner violence?
ADLs/IADLs/AADLs: (for geriatrics or adults with disabilities)
Review of Systems
Only include what is pertinent to the problem.
(these are the official 14 systems used for Evaluation and Management Services (EMS) recognized by DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services). These are usually listed as negatives and positives after each system heading, but some providers write it out as a paragraph. Samples of things you can write here are found in Bates’ guide to Physical Assessment and History Taking, on page 12 and 13.
· Constitutional
· Eyes
· Ears, Nose, Throat
· Cardiovascular
· Respiratory
· Gastrointestinal
· Genitourinary
· Musculoskeletal
· Integumentary/Breast
· Neurologic
· Psychiatric
· Hematologic/Lymphatic
· Endocrine
· Allergic/Immunologic
Objective
Physical Exam:
Vital Signs along with height, weight, BMI (and for children < 2, head circumference and length vs height)
Only include what is pertinent to the problem. WNL or “denies” is not acceptable.
Physical
General survey:
Head:
Eyes:
Ears:
Nose:
Throat:
Neck:
CV:
Pulm:
Abdomen/GI:
GU:
M/S:
Lymph:
Skin:
Neuro:
Psych:
Assessment:
Differential Diagnosis (this is your critical thinking analysis of all the subjective and objective data)
1 (and a brief reason why you ruled it in/out)
2 (and a brief reason why you ruled it in/out)
3 (and a brief reason why you ruled it in/out) – at least 3 minimum should be on all your notes
4 (and a brief reason why you ruled it in/out)
5 (and a brief reason why you ruled it in/out)
Diagnosis: Above list is your differentials. Choose one and make sure you indicate your final diagnosis somehow. Don’t leave other providers guessing which one you chose.
Plan:
-Diagnostic Plan (xrays, labs, PFTs, etc): Be specific. Do not write “blood work” or Xray. Write out specific type of Xray and body part, scan, US, or lab you want drawn.
Therapeutic Plan (meds): You need to be specific. The longer you are in clinicals, the more is expected. For this course, at minimum provide drug name, dosage, timing.
In future clinicals you will be expected to write out concentration (as applies for certain drugs), # dispensed, and any refills.
-Referrals
As needed to specialists, dieticians, physical therapy, mental health, ER, support groups, etc.
-Education and Follow up Plan: (Give patient specific instructions on when to f/u and include when to RTC sooner if worse, or when to go to ER and document this education in your note. Also discuss and document medications – reasons for prescribing, doses, how to take it, and expected side effects. Make sure to tell pt when to go to lab, and if it’s fasting lab. Document it all).
PHYSICAL EXAM
Cognition
_____ 1 Level of Consciousness (describe)
_____ 1 Orientation (assess orientation to person, place, time, event)
_____ 1 Speech (must verbally state assessment of speech)
_____ 1 Memory (performs both a recent and a remote memory test)
_____ 1 Reasoning (performs one reasoning/judgement test)
Cranial Nerves (student needs to state the number and name of each cranial nerve)
_____ 1 I Olfactory – Identifies odors with eyes closed, each nare at a time
II Optic:
_____ 1 Snellen Chart or gross screening each eye separately and then both eyes together at 6 feet with handheld chart or 20 feet with wall chart
_____ 1 Peripheral vision – visual fields by confrontation, each eye
_____ 2 Funduscopic (look at retina, optic disc/cup, vessels)
_____ 1 procedure (R eye of patient to R eye of examiner)
III Oculomotor
_____ 1 EOMs specifically for III (all but lateral and medial/downard)
_____ 1 pupillary reflex directly
_____ 1 pupillary reflex consensually
_____ 1 nystagmus (verbalize if present, and how many beats)
IV Trochlear
_____ 1 EOMs downward and medially
V Trigeminal
_____ 1 bilateral sensation testing of forehead, cheek, AND jaw using sharp and dull
_____ 1 opening jaw against resistance
VI Abducens
_____ 1 EOMs laterally
VII Facial
_____ 1 upper 7th – wrinkle forehead
_____ 1 lower 7th – puff cheek or smile
VIII Acoustic
_____ 1 Whisper, watch tick (each ear)
_____ 1 Weber and Rinne – each ear
IX, X Glossopharyngeal & Vagus
_____ 1 uvula movement with “aaah”
_____ 1 swallowing and gag (may verbalize do not need to demo gag)
XI Spinal Accessory
_____ 1 sternocleidomastoid strength against resistance
_____ 1 trapezius strength
XII Hypoglossal
_____ 1 moves tongue in midline
_____ 1 test strength with tongue blade or push tongue against cheek
Cerebellum
_____ 1 general gait
_____ 1 tandem walk
_____ 1 walk on heels
_____ 1 walk on toes
_____ 1 Romberg, and pronator drift
_____ 1 rapid alternating movements (hands/lap or finger to nose to finger)
_____ 1 patient instruction
Sensory System
_____ 1 Joint position sense, eyes closed
_____ 1 2 point discrimination
_____ 1 stereognosis OR graphesthesia
Upper extremities
_____ 1 superficial tactile sensation – (cotton ball)
_____ 1 superficial pain sensation – (pin prick)
Lower extremities
_____ 1 superficial tactile sensations- (cotton ball)
_____ 1 superficial pain sensations – (pin prick)
_____ 1 vibration sense
_____ 1 patient instruction
Motor System
Upper extremities: deltoids, triceps, biceps
_____ 1 strength
_____ 1 comparison side to side
_____ 1 hand grip
_____ 1 finger strength
Lower extremities: quads, hamstrings, hip abductors, and adductors
_____ 1 strength
_____ 1 comparison side to side
Reflexes
Deep tendon reflexes (bilateral)
_____ 2 biceps
_____ 2 triceps
_____ 2 patellar
_____ 2 Achilles
Superficial reflexes
_____ 2 plantar (babinski)
