TOPIC – WELLNESS/ ANNUAL CHECK-UP Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in’ s Score must be less than 10% or will n

Grading Rubric

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 pa8ents. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1) Iden2fying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The pa8ent complaint should be given in quotes. If the pa8ent has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjec8ve and under the appropriate number.

2) Subjec2ve Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Loca8on, quality , quan8ty or severity, 8ming, seMng, factors that make it beNer or worse, and associate manifesta8ons.(10pts).

b) Review of systems of associated systems, repor8ng all per8nent posi8ves and nega8ves (10pts).

c) Any PMH, family hx, social hx, allergies, medica8ons related to the complaint/problem (10pts). If more than one chief complaint, each should be wriNen u in this manner.

3) Objec2ve 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 iden8fied in 2b.(10pts).

b) Per8nent posi8ves and nega8ves must be documented for each relevant system.

c) Any abnormali8es must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, posi8ve/ nega8ve, 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 sec8on divided into separate numbered sec8ons.

6) Subjec2ve/ Objec2ve, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differen8al 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 subjec8ve sec8on and then the assessment and plan. The management should be consistent with the assessment/ diagnoses iden8fied.

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

Comments:

Total Score: ____________ Instructor: __________________________________

Guidelines for Focused SOAP Notes · Label each sec2on of the SOAP note (each body part and system).

· Do not use unnecessary words or complete sentences.

· Use Standard Abbrevia2ons

S: SUBJECTIVE DATA (informa2on the pa2ent/caregiver tells you).

Chief Complaint (CC): a statement describing the pa8ent’s symptoms, problems, condi8on, diagnosis, physician-recommended return(s) for this pa8ent visit. The pa8ent’s own words should be in quotes.

History of present illness (HPI): a chronological descrip8on of the development of the pa8ent's chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Loca8on, Dura8on, Characteris8cs, Aggrava8ng Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last pa8ent encounter.

Past Medical History (PMH): Update current medica8ons, allergies, prior illnesses and injuries, opera8ons and hospitaliza8ons allergies, age-appropriate immuniza8on status.

Family History (FH): Update significant medical informa8on about the pa8ent's family (parents, siblings, and children). Include specific diseases related to problems iden8fied in CC, HPI or ROS.

Social History(SH): An age-appropriate review of significant ac8vi8es that may include informa8on such as marital status, living arrangements, occupa8on, history of use of drugs, alcohol or tobacco, extent of educa8on and sexual history.

Review of Systems (ROS). There are 14 systems for review. List posi8ve findings and per8nent nega8ves in systems directly related to the systems iden8fied in the CC and symptoms which have occurred since last visit; (1) cons8tu8onal symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointes8nal, (7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13) hematological/lympha8c, {14) allergic/immunologic. The ROS should mirror the PE findings sec8on.

0: OBJECTIVE DATA (informa2on you observe, assessment findings, lab results).

Sufficient physical exam should be performed to evaluate areas suggested by the history and pa8ent's progress since last visit. Document specific abnormal and relevant nega8ve findings. Abnormal or

unexpected findings should be described. You should include only the informa8on which was provided in the case study, do not include addi8onal data.

Record observa2ons for the following systems if applicable to this pa2ent encounter (there are 12 possible systems for examina2on): Cons8tu8onal (e.g. vita! signs, general appearance), Eyes, ENT/ mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lympha8c/immunologic/lab tes8ng. The focused PE should only include systems for which you have been given data.

NOTE: Cardiovascular and Respiratory systems should be assessed on every pa8ent regardless of the chief complaint.

Tes2ng Results: Results of any diagnos2c or lab tes2ng ordered during that pa2ent visit.

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

List and number the possible diagnoses (problems) you have iden8fied. These diagnoses are the conclusions you have drawn from the subjec8ve and objec8ve data.

Remember: Your subjec2ve and objec2ve data should support your diagnoses and your therapeu2c plan.

Do not write that a diagnosis is to be "ruled out" rather state the working defini8ons of each differen8al or primary diagnosis (es).

For each diagnoses provide a cited ra8onale for choosing this diagnosis. This ra8onale includes a one sentence cited defini8on of the diagnosis (es) the pathophysiology, the common signs and symptoms, the pa8ents presen8ng signs and symptoms and the focused PE findings and tests results that support the dx. Include the interpreta8on 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 pa8ent). Each step of your plan must include an EBP cita8on.

1. Medica2ons write out the prescrip8on including dispensing informa8on and provide EBP to support ordering each medica8on. Be sure to include both prescrip8on and OTC medica8ons.

2. Addi2onal diagnos2c tests include EBP cita8ons to support ordering addi8onal tests

3. Educa2on this is part of the chart and should be brief, this is not a pa8ent educa8on sheet and needs to have a reference.

4. Referrals include cita8ons to support a referral

5. Follow up. Pa8ent follow-up should be specified with 8me or circumstances of return. You must provide a reference for your decision on when to follow up.

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Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C

Soap Note # ____ Main Diagnosis: Z00.01-Annual Wellness Check up

PATIENT INFORMATION

Name S.N.

Age: 55 yrs

Gender at Birth: Male

Gender Identity: Male

Source: Patient

Allergies: Denies food, environmental, or drug allergy

Current Medications: Denies use of medications. Takes no herbal medicines or supplement

medications.

PMH: He has no history of hospitalizations. Denies chronic illnesses such as cancer, HTN,

psychiatric diseases, asthma, or diabetes.

Immunizations: COVID 19 vaccine on 10/12/2021. He received the influenza vaccine on

5/2021. Tdap booster was given in 2010. He received all childhood immunizations but was

unable to recall the exact dates.

Preventive Care: RBS done on 20/3/2021. B.P. measurements taken on 20/3/2021

Surgical History: No history of recent or previous surgeries.

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Family History: Raised by biological parents. His mother is 78years and has HTN and diabetes.

Father is 85 years with no chronic illness. His maternal grandfather died at 80 years and had a

history of BPH and HTN.

Social History: He is a small-scale farmer. Married to one wife.Has three children. He neither

smokes nor drinks.

Sexual Orientation: He has one wife, and he is heterosexual

Nutrition History: He takes a balanced diet. He avoids fat-rich diets and processed foods. He

takes a fruit every day in the morning. He drinks seven glasses of water every day. He does not

drink sweetened drinks or coffee.

Subjective Data:

Chief Complaint: "I am feeling great, but I am here for my annual check-up."

Symptom analysis/HPI: The patient's last annual check-up was in May 2021. The patient

reports the absence of any abnormal laboratory or physical findings during that check-up. His

previous eye examination was on October 2021. His last dental review was in November 2021.

Colonoscopy and PSA test were done in January 2018. His previous B.P. screening, Blood Sugar

Screening were done in March 2021. Lip profile tests were done in January 2017. There were no

other current concerns or complaints by the patient.

Review of Systems (ROS

CONSTITUTIONAL: No fatigue, chills, general body weakness, night sweats, or fever

RESPIRATORY: No dyspnea, wheezing, chest pains, or cough

GASTROINTESTINAL: No nausea, abdominal pain, vomiting, or diarrhea

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NEUROLOGIC: No numbness, loss of consciousness, tingling, or confusion

HEENT: H: no dizziness, headache, or confusion. Eyes: no itching, pain, diplopia, or blurry

vision Ears: no pain, hearing loss, tingling sensation, or discharges Nose: No bleeding, itching,

or discharge o Throat: no sore throat, edema, or voice changes

CARDIOVASCULAR: no chest pains, palpitations,dizzness or edema

GENITOURINARY: no dysuria, discharge, urinary urgency, or hematuria

MUSCULOSKELETAL: no muscle pains, joint swelling, joint pain, or muscle spasms

SKIN: no hives, skin rashes, or hyperpigmentation

Objective Data:

VITAL SIGNS: BP-110/90 mmHg, RR 19, Pulse rate 70b/min . SPo2 is 100%. Height-180cm,

Weight-63kg, computed BMI-22.5

GENERAL APPEARANCE: A white male, seated, alert and well-nourished, with no signs of

respiratory distress. There is no pallor, jaundice, cyanosis, dehydration, edema, or

lymphadenopathy.

NEUROLOGICAL: Normal speechA& O x3, typical gait, no tremors, normal speech, no

cerebellar S/S, or motor-sensory loss.

RESPIRATORY: Chest wall is symmetrical, rises following respiration, no visible masses or

scars, no tenderness, percussion note is tympanic, bilateral entry of air, breath sounds were

normal following auscultation.

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CARDIOVASCULAR: Normoactive precordium, palpable apical pulse mid-clavicular line at

the 5th ICS, regular H.R., no thrills, no heaves, On auscultation, there were no murmurs, and S1

and S2 were heard.

GASTROINTESTINAL: Flat abdomen, umbilicus everted, moving with respiration, no

masses, no tenderness or organomegaly; warm. Normoactive bowel sounds were heard.

INTEGUMENTARY: Dark, warm, and dry. No rashes, abrasions, lesions, or hives

HEENT: H: Normocephalic, no scars, masses, or bruises. E: Pupils are equal, round, and

reactive to light, with no discharges. E: no ear discharges or impacted wax N: Symmetrical,

patent nasal nares, no discharge or bleeding.

Neck: No distended veins or lymphadenopathy and supple

MUSCULOSKELETAL: No abnormalities, normal gait, normal reflexes, no deformities, and

normal ROM.

ASSESSMENT:

55-year-old S.N. came to our clinical for his annual check-up. There are no current complaints.

His last yearly check-up showed no abnormal findings. His past check-ups were eye exam,

dental exam, Prostate screening, colonoscopy, lipid profile check-up, and B.P. and B.S.

screenings mother has hypertension and diabetes. His maternal grandfather had a history of

hypertension and BPH. On general and physical examination, there were no abnormal findings

noted.

Main Diagnosis

-1. ICD Z00.00- Annual checkup with no abnormal findings.

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CDC recommends the performance of routine check-ups annually and lab testing to aid in

identifying any health disorders to facilitate early medications and management (CDC,2020).

The patient requires his annual check-up this year.

Preventative Service Task Recommended Screenings:

2. PSA screening-ICD 10 –CM Z12.5. This is essential for screening for malignant cancers of the

prostate.PSA screening is vital in all men above 50 years because of the risk of developing

prostate cancer (Catalona,2018). The patient is at risk of prostate cancer or BPH because of his

old age and a positive family history of BPH.

3. Update for immunization-ICD-10-CM-Z23-which is the encounter for immunization.CDC

recommends that every adult be given a single dose of Tdap and then Td or a booster for Tdap

after ten years (Hibberd,2020). Mr. SN has his immunization updated apart from Tdap.

4. Colonoscopy- ICD 10 -CM Z12.11, which is for encounter for screening for the malignant

cancers of the colon. Colonoscopy is a requirement for individuals above 50 years as it will help

in the early diagnosis of benign or malignant lesions in the rectum or the colon (Saito et

al.,2021).

5. Blood Pressure screening-ICD 10-CM Z01.30 is the encounter for assessing blood pressure

with no abnormal findings. B.P. should be regularly checked in adults above 50 years (Carey et

al.,2018). This patient is at risk of developing HTN because of the positive family of HTN.

6. Blood Sugar Screening- ICD 10-CM R73.09, the code for the HBa1c blood test. This will help

rule out diabetes mellitus and is a requirement for people above 45 years. The patient is at risk of

developing D.M. because of the positive family history.

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7. Lipid profile Check-ICD 10-CM Z13.220 in assessing lipid metabolism errors, the cholesterol

and lipid-protein levels in the blood (Vijan & Elmore, 2020). CDC recommends that adults

above 20 years have cholesterol check-ups every five years (CDC,2020).

PLAN:

Investigations

-CBC- To investigate the white blood cell differentials, RBC, and platelet

-Urinalysis-To assess any abnormalities in the urine

-UECs-To assess the electrolytes

-Lipid tests-Helps in the assessment of the levels of LDL, cholesterol, T.G.s, and HDL

-ECG and ECHO- To assess the electrical activity of the heart and any heart disorders

-Renal function tests-To assess any kidney problems

-TSH-For assessment of any thyroid disorders.

Education

1. Continue monitoring any health changes, and for any threatening health conditions, call,911

2. Have a physical exercise plan at least exercise four times a week

3. Continue with his diet and maximize taking a balanced diet, more fruits and vegetables, and

drinking seven glasses of water daily.

Follow-ups

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Advise the patient to return to the hospital after one week to assess his laboratory

findings. He can book an appointment or make a call in case of any health issues. His next

annual check-up is to be scheduled for January 2023.

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References

Carey, R. M., Whelton, P. K., & 2017 ACC/AHA Hypertension Guideline Writing Committee*.

(2018). Prevention, detection, evaluation, and management of high blood pressure in

adults: synopsis of the 2017 American College of Cardiology/American Heart

Association Hypertension Guideline. Annals of internal medicine, 168(5), 351-358.

https://doi.org/10.7326/M17-3203

Catalona, W. J. (2018). Prostate cancer screening. Medical Clinics, 102(2), 199-214.

https://doi.org/10.1016/j.mcna.2017.11.001

Diphtheria, tetanus, and pertussis vaccine recommendations. (2020). Centers for Disease Control

and Prevention. Retrieved January 31, 2021, from

https://www.cdc.gov/vaccines/vpd/dtap-tdap-td/hcp/recommendations.html

Hibberd, P. L. (2020). Tetanus-diphtheria toxoid vaccination in adults. UpToDate. Retrieved

February 1, 2021, from https://www.uptodate.com/contents/tetanus-diphtheria-toxoid-

vaccination- in-adults

Saito, Y., Oka, S., Kawamura, T., Shimoda, R., Sekiguchi, M., Tamai, N., … & Inoue, H. (2021).

Colonoscopy screening and surveillance guidelines. Digestive Endoscopy, 33(4), 486-

519. https://doi.org/10.1111/den.13972

Vijan, S., & Elmore, J. G. (2020). Screening for lipid disorders in adults. UpToDate. Waltham,

MA: UpToDate. https://www.medilib.ir/uptodate/show/4553