Expanded Typhon Case Logs (SOAP)

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Expanded Typhon Case Logs (SOAP)

  • Create 10 different Soap notes addressing different women health issues (pediatrics/adolescent only. The soap notes must address the Pediatric’s health population only. Please address the ROS(review of systems),Include OB history if any, and PE(physical examination).In your soap template include medications, ICD 10 diagnosis codes ,CPT billing codes and referrals if needed.

Notes should vary and address different health issues

You may not repeat a topic more than twice.

  • Notes are evaluated by a scoring rubric
  • Construction of your SOAP note should be aimed at achieving a score of

“proficient” in each category. Failure to achieve a proficient rating for each of the evaluation criterion, represented in the rubric, by the end of the course will require revision of the final SOAP note submitted until successful. Failure to do so results in failure meet the clinical requirements of the course and failure of the course.​

Expanded Typhon Case Logs

Documentation Requirements

ALL Typhon Case Logs Must Include:

  •   Patient Demographics Section:
  • o Age
  • o Race
  • o Gender
  •   Clinical Information Section:
  • o Time with Patient
  • 
o Consult with Preceptor
  • o Type of Decision Making
  • o Student Participation
  • o Reason for visit
  • o Chief Complaint
  • o Social Problems Addressed
  •   Medications Section:
  • o # OTC Medications taken regularly
  • o # Prescriptions currently prescribed
  • o # New/Refilled Prescriptions This Visit
  •   ICD 10 Codes Category:
  • o For each diagnosis addressed at the visit
  •   CPT Billing Codes Category:

o Evaluation and management code

o – Procedure codes (Pap smear, destruction of lesion, sutures, vaccination

administration, etc.)

Other Questions About This Case Category:

o Age Range Revised 1/3/19

o Patient type

o HPI

o Patients Primary Language

  • §  Notes are evaluated by a scoring rubric
  • §  Construction of your SOAP note should be aimed at achieving a score of

“proficient” in each category. Failure to achieve a proficient rating for each of the evaluation criterion, represented in the rubric, by the end of the course will require revision of the final SOAP note submitted until successful. Failure to do so results in failure meet the clinical requirements of the course and failure of the course.

SOAP Note Format

All sections should be addressed as pertinent to the presenting chief complaint. Refer to the rubric and the format below.

*Subjective:

CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words, or paraphrased.

HPI: history of present illness – 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]

PMH: past medical history – This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.

Allergies: State the offending medication/food and the reactions. Medications: Names, dosages, and routes of administration.

Revised 8/31/18

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Social history: 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.

Family history: Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known.

Health Maintenance/Promotion: (Required for annual wellness or physical exams.) Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines.

ROS: review of systems – this is to make sure you have not missed any important symptoms, particularly in areas that you have not already thoroughly explored while discussing the history of present illness. You would also want to include any pertinent negatives or positives that would help with your differential diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc. While the list below is provided for your convenience it is not to be considered all-encompassing and you are expected to include other systems/categories applicable to your patient’s chief complaint.

General: May include if patient has had a fever, chills, fatigue, malaise, etc. Skin:
HEENT: head, eyes, ears, nose and throat
Neck:

CV: cardiovascular Lungs:
GI: gastrointestinal GU: genito-urinary PV: peripheral vascular MSK: musculoskeletal Neuro: neurological Endo: endocrine Psych:

*Objective:

PE: physical exam – either limited for a focused exam or more extensive for a complete history and physical assessment. This area should confirm your findings related to the diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical

Revised 8/31/18

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examination of CV and lungs. While the list below is provided for your convenience it is not to be considered all-encompassing and you are expected to include other systems/assessments applicable to your patient’s chief complaint. Ensure that you include appropriate male and female specific physical assessments when applicable to the encounter. Your physical exam information should be organized using the same body system format as the ROS section. Appropriate medical terminology describing the objective examination is mandatory.

Gen: general statement of appearance, if there is any acute distress. VS: vital signs, height and weight, BMI
Skin:
HEENT: head, eyes, ears, nose and throat

Neck:

CV: cardiovascular

Lungs:

Abd: abdomen

GU: genito-urinary

PV: peripheral vascular

MSK: musculoskeletal

Neuro: neurological exam

Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).

*Assessment:

Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis. A statement of current condition of all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication). Remember the S and O must support this diagnosis. Pertinent positives and negatives must be found in the write-up.

*Plan:

These are the interventions that relate to each individual diagnosis. Document individual plans directly after each corresponding assessment (Ex. Assessment- Plan). Address the following aspects (they should be separated out as listed below):

Diagnostics: labs, diagnostics testing – tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.

Therapeutic: changes in meds, skin care, counseling Include full prescribing dosing information, including quantity and number of refills for any new or refilled medications. Pay attention to pediatric dosage.

Reminder: Clinical documentation is confidential.

Educational: information clients need in order to address their health problems. Include follow- up care. Anticipatory guidance and counseling.

Consultation/Collaboration: referrals, or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.

Last Updated on May 17, 2019 by EssayPro