Read over the SOAP note and formulate a primary diagnosis.? Based on the diagnosis complete the SOAP note with the details that would be expected for the diag
Directions: Read over the SOAP note and formulate a primary diagnosis. Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.
- Upload a copy of your completed SOAP note.
- Upload a copy of the evaluation & management score sheet.
Case Study: A 32-year-old woman presents for evaluation of a lump that she noticed in her right breast on self-examination. She says that while she does not perform breast self-examination often, she thinks that this lump is new. She denies nipple discharge or breast pain, although the lump is mildly tender on palpation. She has never noticed any breast masses previously and has never had a mammogram. She has no personal or family history of breast disease. She takes oral contraceptive pills (OCPs) regularly, but no other medications. She does not smoke cigarettes or drink alcohol Links to an external site.. She has never been pregnant. On examination, she is a well-appearing, somewhat anxious, and thin woman. Her vital signs are within normal limits. On breast examination, in the lower outer quadrant of the right breast, there is a 2-cm, firm, well-circumscribed, freely mobile mass without overlying erythema that is mildly tender to palpation. There is no skin dimpling, retraction, or nipple discharge. While no other discrete breast masses are palpable, the bilateral breast tissue is noted to be firm and glandular throughout. There is no evidence of axillary, supraclavicular, or cervical lymphadenopathy. The remainder of her physical examination is unremarkable.
SOAP NOTE GRADING RUBRIC
Guidelines:
1-Use the case study in the description to complete the assignment. Fill in the missing details for each required section that would be expected for the diagnosis.
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SUBJECTIVE Analysis (0.2 POINT) |
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1-Subjective section should include: a-Chief complaint (CC) b-History of present illness (HPI)- All 7 attributes (location, quality, quantity or severity, timing including onset, frequency, and duration, setting in which it occurs, aggravating or relieving factors, and associated symptoms) c-Past history (Medical, Surgical, Obstetric/Gynecology, Psychiatric) d-family history (3 generation pedigree of first-degree relatives, i.e. parents, siblings, children) e. Personal and social history (i.e. sexual history 5p’s) f. Review of systems (ROS, pertinent positives and/or negatives) g. Developmentally appropriate-i.e. developmental history if peds, functional assessment and/or dementia screen if elderly a-Identified and collected the necessary data b-Categorized and organized data using the appropriate format c-Incorporated all pertinent data/facts d- Used proper documentation and proper billing code e- PATIENT’S CULTURE MUST BE NOTED |
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OBJECTIVE (0.2POINT) |
Score received |
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1-Objective section should include: a. General survey b. Vital Signs (including BMI and growth chart if applicable) c. All other necessary body systems d. Diagnostic test if available a. Identified and collected the necessary data b. Categorized and organized data using the appropriate format c.Incorporated all pertinent data/facts d. Used proper documentation and billing code |
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ASSESSMENT (0.2 POINT) |
Score received |
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1- Identified correct diagnosis, ICD-10 code, and correct differential diagnosis a-Filtered relevant data from irrelevant data b.-Interpreted relationships/patterns among data (e.g., noted trends) c.Integrated information to arrive at diagnosis d.Identified risk factors d. Used proper documentation |
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PLAN Analysis (0.2 POINT) |
Score received |
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a-Recommended an appropriate plan for each problem b-Included recommendations for non-drug and drug therapy c-Included recommendations for monitoring d- Included health education e- Included followup & referrals f- include cultural considerations of patient care Incorporate the patient's culture on the demographic section on SOAP notes. |
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FORMAT (0.2 POINT) |
Score received |
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1- APA 2- References Current (at least two references, one of which needs to be up to date and the other a clinical practice guideline from a peer reviewed journal article or national organization such as AAFP, ACOG, USPSTF) 3- Writing clear, concise |
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TOTAL: /1 |
SOAP FORMAT & RUBRIC
Initials of Patient:
Patient Age:
Patient Ethnicity:
Initials of Provider:
Clinical Setting:
Patient Status: ____New ____Established
SUBJECTIVE DATA; 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
Quantity or Severity
Timing (Onset, Duration, Frequency)
Setting
Aggravating and relieving Factors
Associated Symptoms
· Pertinent Positives and Negatives if it relates to the differential diagnosis of the chief compliant
Past history (include dates):
PMH
· (Chronic illness (date of onset), hospitalizations (dates), number and gender of sexual partners, risky sexual practices)
· Medications: Dose, route, frequency
· Allergies: Medications, Foods, Other Allergens
PSH
· (Dates, indications, and types of operations)
Past Psychiatric Hx
· (Illness and timeframe, diagnosis, hospitalizations and treatments)
Obstetrical/Gynecological (obstetric history, menstrual history,
Contraceptive history, and sexual history)
Obstetrical History
· (Gravida-Para-TPAL)
Menstrual History
· (Menarche, LMP, PMP, regular/irregular, frequency, duration, quality of flow, Menopause, Post-menopausal bleeding, HRT)
Contraceptive History
· The types of contraceptive being used, the dates of unprotected sex)
Sexual History
· (Five P’s: Partners, Practices, Prevention of Pregnancy, Protection from STI’s, and history of STI’s)
Pregnancy and Birth History
· Maternal health: Gestational or chronic illness (i.e., gestational diabetes, preeclampsia) complications during pregnancy, infections, drugs, alcohol, illicit drug use, and medications.
· Gestational age at delivery
· Labor and delivery length: Length of labor, fetal distress, type of delivery (vaginal or cesarean)
· Neonatal period: Apgar scores, need for intensive care, jaundice, birth injuries, length of stay, birth weight.
Developmental History
· Age at which milestones were achieved and developmental abilities
· School- present grade, specific problems, interaction with peers
· Behavior – enuresis, temper tantrums, thumb sucking, pica, nightmares
Feeding History
· Breast or bottle fed, types of formula, frequency and amount, reasons for any changes in formula
· Solids – when introduced, problems created by specific types
· Fluoride use
Health Promotion/Maintenance
· Immunizations, Eye exams, dental exams, lead screening, lipid,
Hemoglobin. Colonoscopy, Annual Physical, Mammography,
PAP, 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
Complementary/Alternative Care Practices:
Activities of Daily Living/Hobbies/Interests
Type of Family (Nuclear, Extended etc.)
Occupation of parents
Work History
Financial History
Diet
Exercise
Use of alcohol, smoking, or recreational drugs
Living Arrangements and conditions- school/daycare
Travel History
Social Support
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:%
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