Elements for the SOAP charting note include: Chief Complaint including the length of time of the problem Subjective: History obtained in the small group session Objective: Physical exam findings that support the most likely diagnosis (this is written only, no exam is performed), including Point-of Care-Testing (POCT) if appropriate to support your primary diagnosis (help to rule it in or out) Assessment: Diagnosis (the most likely) with ICD 10 diagnostic code and 3 differential diagnosis AND a health promotion/wellness issue that needs to be addressed, i.e smoking, diet, safer sex, exercise, safety issue etc Plan: Anticipated Management plan for the likely diagnosis and health promotion issue. How do you think the illness and health promotion issues might be managed?
NOTE- CORRECTIONS ON LAST SOAP NOTE
— Always use patient initials (pt name was Mary Weathers, not Maria).
- You are missing the pt’s DOB, initials, and person providing the info in the identifying/biographical section.
*Please review the rubric as you are completing the assignments.
- Missing documentation regarding pt’s last medical visit.
OLDCARTS:
- Characteristics: You documented associated symptoms, however you missed the description/characteristic of the pain. Pt described chest and temporal HA as “aching”.
- Relieving Factors: Missing documentation regarding pt’s statement that IBU decreased chest pain form 4/10 to 2/10.
- Severity: Missing pain documentation. You did not document pain level in the vitals section either. You must document pain level anytime the pt c/o pain.
Pt’s Perception:
- Pt mentioned she is not completing her usual walks or volunteering at the local Nx home d/t cough. This info is missing and is worth 2pts on the rubric.
ROS:
- You are missing the entire ROS section. You documented what the pt denies under ” associated symptoms”. This should have been documented under ROS.
Physical Exam:
- You did not document a complete respiratory/cardiac assessment. Your PE assessment should contain lung sounds, heart sounds, rise and fall of chest, etc.
- Under your PE you did not document any negative findings.
Primary Dx:
- You provided the 3 differential Dx, however you did not specify your primary Dx. I assume CAP is your primary Dx, however you are missing the ICD-10 code.
Health Promotion:
- You documented “the pt should exercise smoke cessation”. This is not considered health promotion teaching. Health promotion teaching is educating the pt of the negative affects of smoking, how smoking triggers cough, etc.