Multiple Sclerosis SOAP Note
Multiple Sclerosis SOAP Note
Multiple Sclerosis SOAP Note
SOAP Note _______
NU___:_________ Herzing University |
Name:_________________________
Typhon Encounter #: _____________________ Comprehensive:____Focused:____ |
S: SUBJECTIVE DATA | ||
CC: | What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.
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HPI: | Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
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PMH: | This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
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ALLERGIES | State the offending medication/food and the reactions. | |
MEDICATIONS | Names, dosages, and routes of administration along with indication of use.
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SH | Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.
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FH | Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known.
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HEALTH PROMOTION & MAINTENANCE | Required for all SOAP notes: Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams.
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ROS
(put N/A in sections not completed day of exam) |
Constitutional | |
Head | ||
Eyes | ||
Ears, Nose, Mouth, Throat | ||
Neck | ||
Cardiovascular/Peripheral Vascular | ||
Respiratory | ||
Breast | ||
Gastrointestinal | ||
Genitourinary | ||
Musculoskeletal | ||
Integumentary | ||
Neurological | ||
Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) | ||
Endocrine | ||
Hematologic/Lymphatic | ||
Allergic/Immunologic | ||
Other |
A: ASSESSMENT AND DIAGNOSIS | ||
DIAGNOSIS | ICD-10 CODES | |
PRIORITIZE DIAGNOSIS | 1. | |
2. | ||
3. |
VISIT CODES | CPT BILLING CODES | ||
DIAGNOSTICS
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POC TESTING | ||
TESTS REVIEWED |