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 |
