This paper is to follow the format for the discussion of an establish patient, 35y/o complaining of headaches in the last month and two sporadic blood pressure checks at the pharmacy that were high, family history of hypertension and strokes. You can elaborate on this case.
SOAP FORMAT & RUBRIC
Initials of Patient:
Patient Age:
Patient Ethnicity:
Initials of Provider:
Clinical Setting:
Patient Status: ____New ____Established
SUBJECTIVE DATA (30 points); GRADE RECEIVED: _____
Overall Instructions:
1. Identified and collected the necessary data
2. Categorized and organized data using the appropriate format
3. Incorporated all pertinent data/facts
4. Used proper documentation
5. LIST at the end of your subjective section the billing level : Problem Focused, Expanded problem focused, detailed, comprehensive (use guidelines for new vs. established patient
6. Identify cultural influences on care
FORMAT
Chief Complaint:
History of Present Illness:
Location
Quality
Severity
Duration
Timing
Context
Relieving Factors
Exacerbating Factors
Associated Symptoms
Review of Systems:
Constitutional:
Head/face:
Eyes:
Ears:
Nose:
Mouth/Throat/ Neck:
Respiratory:
Cardiac:
Breast:
GI:
GU:
GYN (female):
Reproductive (Male):
Musculoskeletal:
Skin/Integument:
Psychiatric:
Neuro:
Endocrine:
Hematologic/Lymphatic:
Allergic/Immunologic:
Past history (include dates):
PMH
PSH
Past Psychiatric Hx
Obstetrical History
Hospitalizations
Medications: Dose, route, frequency
Allergies: Medications, Foods, Other Allergens
Dietary Hx
Immunizations
Health Promotion: Colonoscopy, Prostate (PSA), BP check, Cholesterol, Annual
Physical, Mammography, PAP, Eye Exam, Dental etc.
Functional Status: ADLs and IADLs
Family History: Alive, Deceased, Age, Diseases, Health Conditions that place patient at risk (ages)
Grandparents
Parents
Siblings
Children
Social History:
Cultural Background
Spiritual History/Religious Affiliation and Practices
Activities of Daily Living/Hobbies/Interests
Type of Family (Nuclear, Extended etc.)
Marital Status
Parental Status
Work History
Financial History
Sexual History/Orientation
Use of alcohol, smoking, or recreational drugs
Living Arrangements
Travel History
Social Support
Determine Which LEVEL of HISTORY (Choose one):
Focused HPI (1-3 findings); ROS N.A; PFSH N.A
Expanded HPI (1-3 Findings); ROS 1 or more; PFSH N.A.
Detailed HPI (4 or more findings); ROS 2-9 systems; PFSH one
Comprehensive HPI (4 or more findings or status of 2 or more chronic/inactive; ROS 10-14; PFSH 2-3 areas
OBJECTIVE DATA (30 points) Grade received_____
Overall Instructions:
1. Identified and collected the necessary data
2. Categorized and organized data using the appropriate format
3. Incorporated all pertinent data/facts
4. Used proper documentation
5. LIST at the end of your subjective section the billing level : Problem Focused, Expanded problem focused, detailed, comprehensive (use guidelines for new vs. established patient
FORMAT:
Vital Signs:
Oxygen Saturation:
Ht:
Wt:
BMI:
Constitutional:
General:
Physical Examination:
Head/face:
Eyes:
Ears:
Nose:
Mouth/Throat/ Neck:
Respiratory:
Cardiac:
Breast:
GI:
GU:
GYN (female):
Reproductive (Male):
Musculoskeletal:
Skin/Integument:
Psychiatric:
Neuro:
Hematologic/Lymphatic/Immunologic:
Determine Billing LEVEL OF PHYSICAL OBJECTIVE EXAM (choose one):
Focused: 1 body area or organ system (1-5 elements);
Expanded problem focused (2-4 body are or organ system (6-11 elements);
Detailed (5-7 see notes);
Comprehensive (8 organ systems see notes);
Laboratory Data Already Ordered and Available for Review (If not done will go in plan):
Diagnostic Procedures/Data Already Ordered and Available for Review (If not done will go in plan):
ASSESSMENT (15 points) GRADE RECEIVED____
1) Main Diagnosis/Problem:
2) Additional Health Problem/Dx:
3) Differential Diagnoses for top diagnoses
4) Identify Risk Factors
PLAN (15 points) GRADE RECEIVED________
For Each Diagnosis or Health Problem Identified as Appropriate:
Additional Laboratory Tests or Diagnostic Data Needed
Pharmacologic Management:
Drug, dose, route, frequency, Disp amount
SIG (write like a prescription)
Non-Pharmacologic Management: i.e. hot packs, ice, position changes, TENS unit etc.
Complementary Therapies:
Health Education:
Referrals:
Follow-up Appointment:
For the Encounter Final Level of Decision Making: (give rationale for level which is based on Hx, physical, Decision making); Choose one
Straightforward:
Low Complexity:
Moderate Complexity:
High Complexity:
Billing Level: Give the reason for the Billing by E and Coding as per Number of Systems Reviewed and Level of Physical Exam.
Patient Status: New or established
Level of history
Level of physical (exam)
Level of Medical decision making
For new pick the lowest of the 3 levels
For established: drop the lowest level then pick 2nd lowest level
ANALYSIS
Write 1-2 paragraph summary listing the subjective and objective data that supports your main diagnosis.
Write 1-2 paragraph summary discussing the plan for the main diagnosis.
GENERAL FORMAT REQUIREMENTS:
References:
1. Analysis must have support from the literature with references within the last 5 years and/or use of clinical evidence-based guidelines. There should be sufficient number of references which are up to date preferably primary sources, research, clinical guidelines etc.
2. Use of APA style of references in reference list
Writing Style:
1. Writing should be clear and concise with appropriate use of medical terminology.
2. Sections identifying subjective data, objective data, assessment, and plan are written in brief short phrases; not full sentences. No need to use the word “patient.”
3. Demonstrate your clinical judgment and decision making and the evidence you are using to support your identification of the diagnoses, health problem, or differential diagnoses and management plan.