Review of systems of associated systems reporting all pertinent positives and negatives

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Review of systems of associated systems reporting all pertinent positives and negatives

Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints?Explain

 

Soap Note

Pick any “ADULT” Acute or Chronic Disease

Must use the sample template for your soap note

Use APA format and must include minimum of 2 Scholarly Citations.

The use of tempates is ok with regards to Turn it in but the Patient History CC HPI The Assessment and Plan should be of your own work and individualized to your made up patient.

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

1) Identifying Data:

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

2) Subjective Data:

This is the historical part of the note.

It contains the following:

  1. a) Symptom analysis/HPI(Location quality quantity or severity timing setting factors that make it better or worse and associate manifestations.(10pts).
  2. b) Review of systems of associated systems reporting all pertinent positives and negatives (10pts).
  3. c) Any PMH family hx social hx allergies medications related to the complaint/problem (10pts).

If more than one chief complaint each should be written u in this manner.

3) Objective Data:

Vital signs need to be present. Height and Weight should be included where appropriate.

  1. a) Appropriate systems are examined listed in the note and consistent with those identified in 2b.(10pts).
  2. b) Pertinent positives and negatives must be documented for each relevant system.
  3. c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles scars). Avoid using “ok” “clear” “within normal limits” positive/ negative and normal/abnormal to describe things. (5pts).

4) Assessment:

Encounter paragraph and diagnoses should be clearly listed and worded appropriately including ICD10 codes.

5) Plan:

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 section divided into separate numbered sections.

6) Subjective/ Objective Assessment and Management and Consistent:

Does the note support the appropriate differential 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 subjective section and then the assessment and plan.

The management should be consistent with the assessment/ diagnoses identified.

7) Clarity of the Write-up:

Is it literate organized and complete?