SOAP Notes Template

 SOAP Notes Template

  A. SUBJECTIVE:

      I. Chief complaint/s: Patient came in with no chief complaints, annual check up

      II. History of the Present Illness: Patient is a 55 y/o American female who presents to the clinic denying any complaints. Came in for annual check up.

      III. Past History

            a. Medical History: HTN diagnosed in 2014, HLD diagnosed in 2014, hypothyroidism

           a). Surgical History: total hysterectomy  

           b). Acute care stay n/a

           c). Gynecological Hx: 2 cesarian birth 1996, 1998

      IV. Family History

            a. Significant Family History – obtained and found not to relate to the patient’s present condition

      V. Social History

           a). Married

           b). sexual history – Monogomous sexual relationship with husband  

           c).  occupation- nanny

            e. Smoking and alcohol consumption history- denies smoking and alcohol consumption

      VI. Allergies:

            NKDA

       VII. Medication History/Review: Glucophage 500mg orally twice a day, Atorvastatin 80mg by mouth once daily at night, Levothyroxine 25mcg orally once daily

      VIII.  Review of Systems:

       1. Constitutional:  Patient denies activity change; appetite change; chills; diaphoresis; fatigue;  fever; unexpected weight change;

       2. HENT: Patient has no congestion; no dental problem; no drooling; no ear discharge; no ear pain;no facial swelling; no hearing loss; no decrease in hearing; no mouth sores; no nosebleed; no postnasal drip; no rhinorrhea; no sinus pain; no sinus pressure; no sneezing; no sore throat; no tinnitus; no trouble swallowing; no voice change;

      3. Eyes: no eye discharge; no eye itching; no eye pain; no eye redness; no photophobia; no visual disturbance

     4. Cardiovascular: denies chest pain; chest discomfort; shortness of breath; leg swelling; palpitation;

    5.  Respiratory: Denies apnea; chest tightness; choking; cough; shortness of breath; no signs of stridor; wheezing;

    6. Gastrointestinal: no abdominal distention; abdominal pain; denies anal bleeding; blood in   stool; constipation; diarrhea; nausea; rectal pain; vomiting;

    7. Endocrine: denies cold intolerance; denies heat intolerance; denies polydipsia; polyphagia; polyuria;

    8. Genitourinary: (-) for difficulty urinating; dysuria;; frequency;

                                   urgency; urine decreased; negative for genital sore; negative hematuria; patient denies menstrual problem; denies pelvic pain; denies  vaginal bleeding; denies vaginal discharge; denies vaginal pain

  9.  Musculoskeletal: denies arthalgias; denies back pain; denies gait problem; denies joint swelling; denies myalgias; denies neck pain; neck stiffness

  10.  Skin /Integumentary and/or breast): Patient has warm skin to touch, skin intact, denies delayed healing, no rashes bruises or bleeding or skin discoloration

  11. Allergy/Immunological: no known drug allergies ;

  12. Neurological: patient is alert and oriented times four, denies dizziness blurriness, or loss of balance

13. Hematologic: Denies Adenopathy; bruising/bleeding easily

 14. Psychiatric: Patient denies agitation; behavioral problem; confusion; decreased concentration; dysphoric mood; hallucinations; hyperactive; nervous/anxious; self- 

                            injury; sleep disturbance; suicidal ideas

B. OBJECTIVE:

1. : 135/67, 82, 16, 98.1*f orally, 100% on room air
2. ; Bilateral vision 18/20, with correction  

1. Constitutional/General: well-developed; well nourished;; cooperative;

2. Head: Normocephalic;  normal  hair distribution;

3. Ears (right and left findings: normal hearing; (-) drainage; (-) swelling;             (-)tenderness; (-)mid ear effusion; (-)foreign body; (-)laceration; (-)mastoid tenderness; (-)hemotympanum (-)injected TM; (-)scarred TM; (-)perforated TM; (-)erythematous TM; (-)retracted TM; (-)bulging TM; (-)decreased TM mobility;

4. Nose: (-) mucosal edema; (-)rhinorrhea; laceration; tenderness; (-)nasal deformity;  (-)septal deviation; (-)septal hematoma; (-)epistaxis; (-)foreign body; (-)frontal sinus tenderness; (-)maxillary sinus tenderness;

5.  Mouth/lip- Uvula midline; normal dentition;  (-) dentures; (-) dental caries; (-) dental abscess; (-) oral lesion; (-) uvula swelling; (-) trismus

 Throat: Oropharynx: clear and moist;  (-) oropharyngeal exudate; (-) posterior oropharyngeal edema; (-) tonsillar abscess; moist membranes; tonsils (right and left) size 0; ­ (-)tonsillar exudate

6. Eyes:

A.  External eyes (right and left):

1. General: normal lids, no foreign bodies; (-) chemosis; (-) discharges; (-) exudate; (-) hordeolum;

 (-) scleral icterus;

2. Conjunctiva: (right and left) (-) injection; ( (-) hemorrhage;

3. Extraocular motions: Normal EOM; (-) nystagmus

4. Pupils: equally round and reactive to light

B. Funduscopic Exam: (right and left) (-) AV nicking; (-) exudate; (-) hemorrhage; (-) papilledema; (-) red reflex; (-) right/left eye venous pulsations; or (-) right and left arteriolar narrowing;

         b. Slit Lamp: (right and left) (-) corneal flare; (-) corneal ulcer; (-) foreign body; (-)hyphema; (-)hypopyon; (-)corneal abrasion; (-)fluorescein uptake; (-)anterior chamber bulge;

7. Neck- Vascular: (-) carotid bruit; normal bilateral carotid pulse; (-) hepatojugular reflux;  (-) Jugular venous distention;

Thyroid- (-) mass; (-) thyromegaly;

Trachea- normal; (-)stridor; (-)tenderness; (-) deviation; Neck musculoskeletal – (+) full passive ROM without pain; supple neck; (-)edema; (-)erythema; (-)neck rigidity; (-) decreased ROM; (-)spinous process tenderness; (-)muscular tenderness; Meningeal: (-)Brudzinski sign; (-) Kernig’s sign;

8. Cardiovascular: regular rhythm; rate – normal; Heart sounds- normal S1, S2, r (-) S3, S4; (-)distant sounds; (-)friction rub (-)gallop; r (-)murmur; (systolic /diastolic and grade of murmur grade1-6/6;; normal pulses; intact/non-intact distal pulses (carotid, radial, femoral, popliteal, DP, PT pulses

9. Respiratory:

            a. Pulmonary effort: (-) respiratory distress; (-) apnea; (-) tachypnea; (-) bradypnea; (-) accessory muscle use;

            b. Breath sounds: bronchovesicular breath sounds; (-) decreased breath sounds; (-) wheezes; (-) rales;

            c. Chest wall: (-) mass; (-) bony tenderness; (-) retraction; (-) deformity;   (-) crepitus; Breast (right and left):  (-) inverted nipple;  (-) mass; (-) nipple discharges; (-) skin change; (-) swelling; (-) tenderness;

10. Abdomen: (-) abnormal pulsation; (-) scars/lesions; Bowel sounds normoactive; (-) abdominal bruit;

 (-) ascites; (-) shifting dullness; (-) epigastric tenderness;

] (-) periumbilical tenderness; (-) suprapubic tenderness; (-) RUQ/RLQ/LUQ/LLQ tenderness; (-) hepatosplenomegaly; (-)ventral hernia; (-)inguinal hernia;

11. Genitourinary:

            A. Female:

Patient denies GU examination at this time.

            12. Musculoskeletal: (right and left): (-) deformity; (-) swelling; (-) bony tenderness; (-) crepitus; (-) effusion; norma, ROM; (-) muscle spasm; (-) pain; decreased capillary refill;

            13. Lymphatics: Left and right (-) submental/ submandibular; tonsillar; preauricular; post-auricular; /occipital/ superficial cervical; deep cervical; posterior cervical/ pectoral/axillary/ lateral/ inguinal/ supraclavicular; epitrochlear adenopathy;

            14. Neurological:

            a. Mental status: alert; lethargic; orientedX4 ; listless; unresponsive;

            b. GCS scale: Total score= 15

                        Eye: 4

                        Verbal: 5-

                        Motor: 6

            c. Cranial nerves= intact; (+)  Sensory: (+) (-)  atrophy; (-) tremor; (-) seizure;

                        2. Coordination: (-) Romberg Test; (-) abnormal coordination;                                     (-) abnormal gait;

            Deep Tendon Reflexes: (Left and right) symmetrical; (-) abnormal DTR’s; (-) Babinski reflex

                        a. Tricep 4-

                        b. Bicep: 4

                        c. Brachioradialis: 4

                        d. Patellar: 4

                        e. Achilles: 4

            15. Skin/Integumentary:

            General – warm; dry; skin intact; (-) diaphoresis; (-)abrasion; (-) burn; (-)bruising; (-) erythema; (-)lesion; (-) laceration; (-) petechiae; (-); (-)pustular; (-) macular; or (-)maculopapular (-)nodular; (-)purpuric; (-)vesicular; (-)popular; Nails: (-) clubbing; (-) cyanosis;

16. Psychiatric:

            a. Attention and Perception: attentive (-) hallucination

            b. Mood and Affect: normal;

            c. Speech: normal; (-) rapid and pressured; (-) slurring; (-)                              delayed speech; (-) tangential speech;

            d. Behavior: normal;

            e. Thought Content: normal (-) plan of suicide; (-) plan of homicide;

            f. Cognition and Memory: normal;

            g. Judgment: normal

C.    ASSESSMENT:  

E785 – Hyperlipidemia, unspecified

I159 – Secondary hypertension, unspecified

E039 – Hypothyroidism, unspecified

D.   PLAN

            1. Diagnostic Plan:

                                                99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family.

and/or family.

                        80050- General health panel This panel must include the following: Comprehensive metabolic panel (80053), Blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004), OR, Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009), Thyroid stimulating hormone (TSH) (84443)

99386

Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years

focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family.

            81007 Urinalysis; bacteriuria screen, except by culture or dipstick

            2. Therapeutic Plan: Continue with current medication

           3. Follow up care/ Referral as applicable. Phone call follow up with Provider with lab results

           4. Patient Education/Health Promotion

Educated patient on hypertension, and blood pressure monitoring, educated on low sodium diet. Re-educated on hyperlipidemia, on low cholesterol diet. Educated patient on hypothyroidism and importance of continuing medication. Educated on signs and symptoms of heart attack and stroke and when to call 911. Re-educated on current medications patient is taking, and side effects.