Executive Solution Overview
– 2 years ago **files (2)** – ## SOAPnote4.docx – ## SOAPTemplateandRubric_Updated.docx **## SOAPnote4.docx** **Please follow APA format, add citations and references. Document will be verified for plagiarism and AI use. Thank you!** **Directions:** Read over the SOAP note and formulate a primary d…
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– 2 years ago
**files (2)**
– ## SOAPnote4.docx
– ## SOAPTemplateandRubric_Updated.docx
**## SOAPnote4.docx**
**Please follow APA format, add citations and references. Document will be verified for plagiarism and AI use. Thank you!**
**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 45-year-old white man presents to your office complaining of left knee pain that started last night. He says that the pain started suddenly after dinner and was severe within a span of 3 hours. He denies any trauma, fever, systemic symptoms, or prior similar episodes. He has a history of hypertension for which he takes hydrochlorothiazide (HCTZ). He admits to consuming a great amount of wine last night with dinner .On examination, his temperature is 98°F, his pulse is 90 beats/min, his respirations are 22 breaths/min, and his blood pressure is 129/88 mm Hg. Heart and lung examinations are unremarkable. The patient is reluctant to flex the left knee, wincing in pain at touch, and has passive range of motion. The knee is edematous, hot to touch, and has erythema of the overlying skin. No crepitation or deformity is apparent. No other joints are involved. Inguinal lymph nodes are not enlarged. Complete blood count (CBC) reveals a white blood cell count of 10,900 cells/mm3 and is otherwise normal.
**## SOAPTemplateandRubric_Updated.docx**
**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.
## | | | | — | — | | | | | **SUBJECTIVE Analysis (0.2 POINT)** | **Score received** | | 1-Subjective section should include:<br>a-Chief complaint (CC)<br>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)<br>c-Past history (Medical, Surgical, Obstetric/Gynecology, Psychiatric)<br>d-family history (3 generation pedigree of first-degree relatives, i.e. parents, siblings, children)<br>e. Personal and social history (i.e. sexual history 5p’s)<br>f. Review of systems (ROS, pertinent positives and/or negatives)<br>g. Developmentally appropriate-i.e. developmental history if peds, functional assessment and/or dementia screen if elderly<br>a-Identified and collected the necessary data <br>b-Categorized and organized data using the appropriate format<br>c-Incorporated all pertinent data/facts<br>d- Used proper documentation and proper billing code<br>e- PATIENT’S CULTURE MUST BE NOTED | | | **OBJECTIVE (0.2POINT)** | **Score received** | | 1-Objective section should include:<br>a. General survey<br>b. Vital Signs (including BMI and growth chart if applicable)<br>c. All other necessary body systems<br>d. Diagnostic test if available<br>a. Identified and collected the necessary data <br>b. Categorized and organized data using the appropriate format <br>c.Incorporated all pertinent data/facts <br>d. Used proper documentation and billing code | | | **ASSESSMENT (0.2 POINT)** | **Score received** | | 1- Identified correct diagnosis, ICD-10 code, and correct differential diagnosis<br>a-Filtered relevant data from irrelevant data <br>b.-Interpreted relationships/patterns among data <br>(e.g., noted trends)<br>c.Integrated information to arrive at diagnosis<br>d.Identified risk factors<br>d. Used proper documentation | | | **PLAN Analysis (0.2 POINT)** | **Score received** | | a-Recommended an appropriate plan for each problem<br>b-Included recommendations for non-drug and drug therapy<br>c-Included recommendations for monitoring <br>d- Included health education<br>e- Included followup & referrals <br>f- include cultural considerations of patient care<br>Incorporate the patient's culture on the demographic section on SOAP notes. | | | **FORMAT (0.2 POINT)** | **Score received** | | 1- APA<br>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)<br>3- Writing clear, concise | | | **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:** **Hematologic/Lymphatic:** **Allergic/Immunologic:** **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 3 or more chronic stable conditions; ROS 10-14; PFSH 2-3 areas** **OBJECTIVE 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** **FORMAT:** **Vital Signs:** **Oxygen Saturation:** **Ht and percentile on growth chart:** **Wt and percentile on growth chart:** **BMI (if applicable):** **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; GRADE RECEIVED____** 1) **Main Diagnosis/Problem:** 2) **Additional Health Problem/Dx:** 3) **Differential Diagnoses for top diagnoses** 4) **Identify Risk Factors** **PLAN; 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:** **Anticipatory Guidance:** **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 M Evaluation 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.**
**## SOAPTemplateandRubric_Updated.docx**
**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.
## | | | | — | — | | | | | **SUBJECTIVE Analysis (0.2 POINT)** | **Score received** | | 1-Subjective section should include:<br>a-Chief complaint (CC)<br>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)<br>c-Past history (Medical, Surgical, Obstetric/Gynecology, Psychiatric)<br>d-family history (3 generation pedigree of first-degree relatives, i.e. parents, siblings, children)<br>e. Personal and social history (i.e. sexual history 5p’s)<br>f. Review of systems (ROS, pertinent positives and/or negatives)<br>g. Developmentally appropriate-i.e. developmental history if peds, functional assessment and/or dementia screen if elderly<br>a-Identified and collected the necessary data <br>b-Categorized and organized data using the appropriate format<br>c-Incorporated all pertinent data/facts<br>d- Used proper documentation and proper billing code<br>e- PATIENT’S CULTURE MUST BE NOTED | | | **OBJECTIVE (0.2POINT)** | **Score received** | | 1-Objective section should include:<br>a. General survey<br>b. Vital Signs (including BMI and growth chart if applicable)<br>c. All other necessary body systems<br>d. Diagnostic test if available<br>a. Identified and collected the necessary data <br>b. Categorized and organized data using the appropriate format <br>c.Incorporated all pertinent data/facts <br>d. Used proper documentation and billing code | | | **ASSESSMENT (0.2 POINT)** | **Score received** | | 1- Identified correct diagnosis, ICD-10 code, and correct differential diagnosis<br>a-Filtered relevant data from irrelevant data <br>b.-Interpreted relationships/patterns among data <br>(e.g., noted trends)<br>c.Integrated information to arrive at diagnosis<br>d.Identified risk factors<br>d. Used proper documentation | | | **PLAN Analysis (0.2 POINT)** | **Score received** | | a-Recommended an appropriate plan for each problem<br>b-Included recommendations for non-drug and drug therapy<br>c-Included recommendations for monitoring <br>d- Included health education<br>e- Included followup & referrals <br>f- include cultural considerations of patient care<br>Incorporate the patient's culture on the demographic section on SOAP notes. | | | **FORMAT (0.2 POINT)** | **Score received** | | 1- APA<br>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)<br>3- Writing clear, concise | | | **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:** **Hematologic/Lymphatic:** **Allergic/Immunologic:** **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 3 or more chronic stable conditions; ROS 10-14; PFSH 2-3 areas** **OBJECTIVE 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** **FORMAT:** **Vital Signs:** **Oxygen Saturation:** **Ht and percentile on growth chart:** **Wt and percentile on growth chart:** **BMI (if applicable):** **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; GRADE RECEIVED____** 1) **Main Diagnosis/Problem:** 2) **Additional Health Problem/Dx:** 3) **Differential Diagnoses for top diagnoses** 4) **Identify Risk Factors** **PLAN; 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:** **Anticipatory Guidance:** **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 M Evaluation 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.**
**## SOAPnote4.docx**
**Please follow APA format, add citations and references. Document will be verified for plagiarism and AI use. Thank you!**
**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 45-year-old white man presents to your office complaining of left knee pain that started last night. He says that the pain started suddenly after dinner and was severe within a span of 3 hours. He denies any trauma, fever, systemic symptoms, or prior similar episodes. He has a history of hypertension for which he takes hydrochlorothiazide (HCTZ). He admits to consuming a great amount of wine last night with dinner .On examination, his temperature is 98°F, his pulse is 90 beats/min, his respirations are 22 breaths/min, and his blood pressure is 129/88 mm Hg. Heart and lung examinations are unremarkable. The patient is reluctant to flex the left knee, wincing in pain at touch, and has passive range of motion. The knee is edematous, hot to touch, and has erythema of the overlying skin. No crepitation or deformity is apparent. No other joints are involved. Inguinal lymph nodes are not enlarged. Complete blood count (CBC) reveals a white blood cell count of 10,900 cells/mm3 and is otherwise normal.
**## SOAPTemplateandRubric_Updated.docx**
**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.
## | | | | — | — | | | | | **SUBJECTIVE Analysis (0.2 POINT)** | **Score received** | | 1-Subjective section should include:<br>a-Chief complaint (CC)<br>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)<br>c-Past history (Medical, Surgical, Obstetric/Gynecology, Psychiatric)<br>d-family history (3 generation pedigree of first-degree relatives, i.e. parents, siblings, children)<br>e. Personal and social history (i.e. sexual history 5p’s)<br>f. Review of systems (ROS, pertinent positives and/or negatives)<br>g. Developmentally appropriate-i.e. developmental history if peds, functional assessment and/or dementia screen if elderly<br>a-Identified and collected the necessary data <br>b-Categorized and organized data using the appropriate format<br>c-Incorporated all pertinent data/facts<br>d- Used proper documentation and proper billing code<br>e- PATIENT’S CULTURE MUST BE NOTED | | | **OBJECTIVE (0.2POINT)** | **Score received** | | 1-Objective section should include:<br>a. General survey<br>b. Vital Signs (including BMI and growth chart if applicable)<br>c. All other necessary body systems<br>d. Diagnostic test if available<br>a. Identified and collected the necessary data <br>b. Categorized and organized data using the appropriate format <br>c.Incorporated all pertinent data/facts <br>d. Used proper documentation and billing code | | | **ASSESSMENT (0.2 POINT)** | **Score received** | | 1- Identified correct diagnosis, ICD-10 code, and correct differential diagnosis<br>a-Filtered relevant data from irrelevant data <br>b.-Interpreted relationships/patterns among data <br>(e.g., noted trends)<br>c.Integrated information to arrive at diagnosis<br>d.Identified risk factors<br>d. Used proper documentation | | | **PLAN Analysis (0.2 POINT)** | **Score received** | | a-Recommended an appropriate plan for each problem<br>b-Included recommendations for non-drug and drug therapy<br>c-Included recommendations for monitoring <br>d- Included health education<br>e- Included followup & referrals <br>f- include cultural considerations of patient care<br>Incorporate the patient's culture on the demographic section on SOAP notes. | | | **FORMAT (0.2 POINT)** | **Score received** | | 1- APA<br>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)<br>3- Writing clear, concise | | | **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:** **Hematologic/Lymphatic:** **Allergic/Immunologic:** **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 3 or more chronic stable conditions; ROS 10-14; PFSH 2-3 areas** **OBJECTIVE 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** **FORMAT:** **Vital Signs:** **Oxygen Saturation:** **Ht and percentile on growth chart:** **Wt and percentile on growth chart:** **BMI (if applicable):** **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; GRADE RECEIVED____** 1) **Main Diagnosis/Problem:** 2) **Additional Health Problem/Dx:** 3) **Differential Diagnoses for top diagnoses** 4) **Identify Risk Factors** **PLAN; 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:** **Anticipatory Guidance:** **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 M Evaluation 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.**
**## SOAPnote4.docx**
**Please follow APA format, add citations and references. Document will be verified for plagiarism and AI use. Thank you!**
**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 45-year-old white man presents to your office complaining of left knee pain that started last night. He says that the pain started suddenly after dinner and was severe within a span of 3 hours. He denies any trauma, fever, systemic symptoms, or prior similar episodes. He has a history of hypertension for which he takes hydrochlorothiazide (HCTZ). He admits to consuming a great amount of wine last night with dinner .On examination, his temperature is 98°F, his pulse is 90 beats/min, his respirations are 22 breaths/min, and his blood pressure is 129/88 mm Hg. Heart and lung examinations are unremarkable. The patient is reluctant to flex the left knee, wincing in pain at touch, and has passive range of motion. The knee is edematous, hot to touch, and has erythema of the overlying skin. No crepitation or deformity is apparent. No other joints are involved. Inguinal lymph nodes are not enlarged. Complete blood count (CBC) reveals a white blood cell count of 10,900 cells/mm3 and is otherwise normal.
**## SOAPTemplateandRubric_Updated.docx**
**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.
## | | | | — | — | | | | | **SUBJECTIVE Analysis (0.2 POINT)** | **Score received** | | 1-Subjective section should include:<br>a-Chief complaint (CC)<br>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)<br>c-Past history (Medical, Surgical, Obstetric/Gynecology, Psychiatric)<br>d-family history (3 generation pedigree of first-degree relatives, i.e. parents, siblings, children)<br>e. Personal and social history (i.e. sexual history 5p’s)<br>f. Review of systems (ROS, pertinent positives and/or negatives)<br>g. Developmentally appropriate-i.e. developmental history if peds, functional assessment and/or dementia screen if elderly<br>a-Identified and collected the necessary data <br>b-Categorized and organized data using the appropriate format<br>c-Incorporated all pertinent data/facts<br>d- Used proper documentation and proper billing code<br>e- PATIENT’S CULTURE MUST BE NOTED | | | **OBJECTIVE (0.2POINT)** | **Score received** | | 1-Objective section should include:<br>a. General survey<br>b. Vital Signs (including BMI and growth chart if applicable)<br>c. All other necessary body systems<br>d. Diagnostic test if available<br>a. Identified and collected the necessary data <br>b. Categorized and organized data using the appropriate format <br>c.Incorporated all pertinent data/facts <br>d. Used proper documentation and billing code | | | **ASSESSMENT (0.2 POINT)** | **Score received** | | 1- Identified correct diagnosis, ICD-10 code, and correct differential diagnosis<br>a-Filtered relevant data from irrelevant data <br>b.-Interpreted relationships/patterns among data <br>(e.g., noted trends)<br>c.Integrated information to arrive at diagnosis<br>d.Identified risk factors<br>d. Used proper documentation | | | **PLAN Analysis (0.2 POINT)** | **Score received** | | a-Recommended an appropriate plan for each problem<br>b-Included recommendations for non-drug and drug therapy<br>c-Included recommendations for monitoring <br>d- Included health education<br>e- Included followup & referrals <br>f- include cultural considerations of patient care<br>Incorporate the patient's culture on the demographic section on SOAP notes. | | | **FORMAT (0.2 POINT)** | **Score received** | | 1- APA<br>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)<br>3- Writing clear, concise | | | **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:** **Hematologic/Lymphatic:** **Allergic/Immunologic:** **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 3 or more chronic stable conditions; ROS 10-14; PFSH 2-3 areas** **OBJECTIVE 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** **FORMAT:** **Vital Signs:** **Oxygen Saturation:** **Ht and percentile on growth chart:** **Wt and percentile on growth chart:** **BMI (if applicable):** **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; GRADE RECEIVED____** 1) **Main Diagnosis/Problem:** 2) **Additional Health Problem/Dx:** 3) **Differential Diagnoses for top diagnoses** 4) **Identify Risk Factors** **PLAN; 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:** **Anticipatory Guidance:** **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 M Evaluation 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.**