SOAP note for Tina Jones on neurologic assessment

SOAP note for Tina Jones on neurologic assessment

SOAP note for Tina Jones on neurologic assessment

SOAP note for Tina Jones on neurologic assessment. (Shadow health assignment, neurologic assessment).
Please see shadow health on tina jones neurologic assessment for the assignment.

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SOAP Note Format

Patient Information:

Initials, Age, Sex, Race, Insurance

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: include all the information regarding the CC using the OLDCART format. If the CC was “Unintentional weight loss”, the OLDCART for the HPI might look like the following example:

Onset: 2 months ago

Location: Generalized

Duration: Steady weight loss, 3-5 pounds per week

Characteristics: Associated with feeling tired, poor appetite, and occasional nausea without vomiting

Aggravating Factors: Food smells increase the frequency of nausea

Relieving Factors: Small, bland meals are better tolerated

Treatment: None reported

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately.

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use, any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: Constitutional: Head: EENT: etc. You may list these in paragraph format or bullet format. Always document the systems in order from head to toe. You may focus the ROS to match the chief complaint unless you are doing a complete health history.

Example of Complete ROS:

CONSTITUTIONAL:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

O.

Physical exam: include the same body systems as in the ROS. Include the assessment data for the system(s) identified in the discussion instructions. Always document in head to toe format i.e. Constitutional: Head: EENT: etc.

Diagnostic results: when available (from today and past recent tests results if pertinent)

A.

Differential Diagnoses (list a minimum of 3differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. Include the ICD9 or ICD10 codes in parentheses next to the diagnosis. Include pertinent positive and negative findings to support your diagnoses from the history and physical exam.

  1. No intervention is self-evident. Provide a rationale and evidence based in-text citation for each intervention

Diagnostics: list tests you will order this visit

Rx: list treatments and medications you will order and “continue previous meds” if pertinent. State dosages, length of treatment and reason for choosing a specific treatment or drug.

Education: think about covering yourself legally; also indicate when written instructions are given.


Referral/Consults: (if any)

SOAP note for Tina Jones on neurologic assessment

Follow up: indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere.

References

You are required to include at least one evidence based peer-reviewed which relates to this case. Be sure to use correct APA 6th edition formatting.

Pre Brief

Two days after a minor, low-speed car accident in which Tina was a passenger, she noticed daily bilateral headaches along with neck stiffness. She reports that it hurts to move her neck, and she believes her neck might be swollen. She did not lose consciousness in the accident and denies changes in level of consciousness since that time. She states that she gets a headache every day that lasts approximately 1-2 hours. She occasionally takes 650 mg of over the counter Tylenol with relief of the pain. This case study will allow you the opportunity to examine the patient’s optic nerve via use of the ophthalmoscope as well as assess her visual acuity. You will need to document your findings using appropriate medical terminology. Be sure to assess for foot neuropathy using the monofilament test.

Reason for visit: Patient presents complaining of headache.

SOAP note for Tina Jones on neurologic assessment

Rubric

Shadow Health Physical Assessment Rubric

Shadow Health Physical Assessment Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeSubjective Data, Organization, Communication, and Summary (DCE Score or transcript)
25.0 pts

Above Average- DCE Score greater than or equal to 93; Comprehensive introduction with expectations of exam verbalized; questions worded in a non-judgmental way; professional language exercised; questions well-organized; appropriate closing with summary of findings verbalized to patient.

21.0 pts

Average- DCE Score greater than or equal to 86-92; Adequate introduction; some questions worded in a non-judgmental way; professional language mostly exercised; questions generally organized; somewhat complete closing.

10.0 pts

Below Average- DCE Score greater than or equal to 80-85; Incomplete introduction; many questions worded in a judgmental way; some professional language exercised; questions somewhat organized; incomplete closing.

0.0 pts

Unsatisfactory- DCE Score less than or equal to 79; Introduction missing; questions worded in a judgmental way; little professional language; questions unorganized; closing missing.

25.0 pts
This criterion is linked to a Learning OutcomeObjective Data, Physical Examination, Interpretation of Findings, Assessment, and Documentation
20.0 pts

Above Average- Physical assessment documentation includes all relevant body systems; all pertinent normal and abnormal findings identified; documentation reflects professional language; treatment plan includes each of the following components: diagnostics, medication, education, consultation/referral, and follow-up planning.

16.0 pts

Average- Physical assessment documentation lacks sufficient details pertaining to one or two relevant body systems; or identifies ≥ 50% of the pertinent normal and abnormal findings; or documentation lacks professional language; or treatment plan lacks one or two components (diagnostics, medication, education, consultation/referral, or follow-up planning).

8.0 pts

Below Average- Physical assessment documentation lacks sufficient details pertaining to three or more relevant body systems; or identifies < 49% of the pertinent normal and abnormal findings; or documentation includes unprofessional language; or treatment plan lacks three or more components (diagnostics, medication, education, consultation/referral, or follow-up planning).

0.0 pts

Unsatisfactory- No physical assessment documentation or no treatment plan.

20.0 pts
This criterion is linked to a Learning OutcomeSelf-Reflection
5.0 pts

Above Average- Responds to three of the three reflection post questions; and provides analysis of performance; and reflection posts written using professional language; and reflection posts demonstrate insight.

3.0 pts

Average- Responds to two of the three reflection post questions; or provides limited self-analysis of performance; or reflection posts are somewhat unclear related to the assignment and the student’s experience; or reflection posts lack insight.

2.0 pts

Below Average- Responds to one of the three reflection post questions; or does not provide self-analysis of performance; or reflections are not related to the assignment and the student’s experience; or does not provide insight

0.0 pts

Unsatisfactory- No reflection posts for the assignment.

5.0 pts

 

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