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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.
Patient Information:
- Initials
- Age
- Sex
- Race
- Insurance
Subjective
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. SOAP note for Tina Jones on neurologic assessment
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. SOAP note for Tina Jones on neurologic assessment
Fam Hx: illnesses with possible genetic pred isposition, 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. SOAP note for Tina Jones on neurologic assessment
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.
Objective
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)
Assessment
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. SOAP note for Tina Jones on neurologic assessment
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 journal article 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. SOAP note for Tina Jones on neurologic assessment
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
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 | ||||
| This criterion is linked to a Learning OutcomeObjective Data, Physical Examination, Interpretation of Findings, Assessment, and Documentation |
|
20.0 pts | ||||
| This criterion is linked to a Learning OutcomeSelf-Reflection |
|
5.0 pts | ||||