Episodic, Comprehensive and Alternative SOAP Note Example

Episodic, Comprehensive and Alternative SOAP Note Example

Episodic Write-up: Episodic visits are mostly encounters which require about one time visit (sometimes with a short follow-up depending on the diagnosis/existing comorbidities), or occurs occasionally.  Episodic visit ROS and physical examination (PE) are targeted and focused on the body system(s) affected.  Examples are URI, bronchitis, seasonal allergic rhinitis, acute pharyngitis, acute gastroenteritis, pneumonia, contact dermatitis, etc.

 

This write-up should be 2-4 pages single spaced and concentrate on the most pertinent information. Not all the systems or sections from a comprehensive write up will be represented. Only the sections and information that are important to this case need be included. This helps clarify your understanding of using only the best/most important tools and information to justify your critical thinking.

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Comprehensive Write-up: Comprehensive visits often requires head to toe or extensive ROS and physical examination (PE). Visits which may necessitate a comprehensive ROS, physical exam, and write-up include annual physical, well woman exam(may not always include head to toe, but could be the only preventive care most women receive), well child exam, new or established patients with complex or chronic diseases or comorbidities, non-specific complaints, such as fatigue, generalized weakness or body ache, dizziness, etc.  This episodic, comprehensive and alternative soap note example  should be 5-8 pages single spaced.

You must know how to delineate which visits are episodic versus comprehensive.  Conducting a comprehensive exam on a patient whose chief complaint and ROS support an episodic visit or write-up may paint a picture of a clueless provider; and can constitute a waste of time for you and the patient. Your patient may not trust your clinical reasoning/judgment (diagnosis/plan of care) if they perceive you are all over the place!  Insurance is not going to pay you more because you decided to complete a comprehensive note on an episodic visit or diagnosis!

Alternative Write-up: Some courses may have specialized write-ups based on a patient with certain demographics or with certain disease process episodic, comprehensive and alternative soap note example. These write ups will follow the same guidelines as comprehensive-write ups.

Case Write-up Outline

 

Following the format of: https://meded.ucsd.edu/clinicalmed/write.htm.

 

Subjective:

CC: This should be in quotes: “I’ve had a cough and sore throat for 2 days”

HPI: One of the most important parts of the assessment. Check the list of important questions to ask (OLD CARTS or PQRST). As you become more proficient in physical exam and lab testing, the HPI does not decrease in importance – your ability to use it in diagnostic reasoning just increases.

Past Medical History: Past or present illness. Be careful with “blindly” copying history from a prior clinical note.

Past Surgical History: Past surgeries and rough dates when possible. Should also include traumas and hospitalizations

Medications: List name, dose, frequency and indication (why are they taking it?) Do NOT omit the indication (reason) for a specific drug being taken. Do NOT omit PRN medications and how often the medications are taken. This is one way to check whether you’ve put all important information in your patient history.  If a patient is taking Metformin and there’s no related information on the history and/or diagnoses list, something is missing.

Allergies: Medications. Food allergies when applicable.

Social History: This includes several factors: alcohol use, cigarette use, sexual history, work history are a few examples. Include health promotion information such as exercise and immunizations. Immunization is important – we want to know the date of an adult patient’s last tetanus immunization. Be specific, don’t just say UTD. For children, list dates for all immunizations.

Family History: It is generally appropriate to go back at least two generations.

Obstetrical History: When appropriate, document number of pregnancies and other relevant information.

Review of Symptoms (ROS): For comprehensive visits: should be extensive and include every system. For episodic visits: Think about your likely differential diagnosis list and tailor your ROS to it. Always address growth and development in pediatric patients. In childbearing women, make sure to document date of last menstrual period (LMP) and methods of contraceptive use on every visit on any woman capable of becoming pregnant (having menses and has not had a tubal ligation/hysterectomy). Every visit – If you order such a medication without documenting the above information, we have to assume that the patient could be pregnant (as would any lawyer in a lawsuit).  For a young teen you can put “not sexually active” (but make sure you have asked).  episodic, comprehensive and alternative soap note example This is sometimes tricky with teens being seen for general health problems but so very important.  If in any doubt, ask the parent to step out for a moment so that you can talk to the teen alone.

Objective

Vital signs (BMI should be included on every visit)

Physical examination

Laboratory data, diagnostic tests, imaging: These should be what is available at the time the visit. Do not include testing that was ordered during the visit but not results were not available.

TIP:

Make sure to proper distinguish between subjective and objective data. Subjective data, as the name suggests, is the information you gather by interviewing the patient, family, or significant other. This will include data from chief complaint, Social/family history, and Review of system (ROS). Objective data will include those information or data you elicited through physical examination, vital signs and/or diagnostic test results. Note that statement such as “Denies chest pain, sob, dysuria, vaginal bleeding, diarrhea, etc.” should be in the subjective section (ROS) of your note, and not in PE section.  Do not write “Alert and oriented; no tenderness; no erythema; breath sounds clear; no spine curvature” under ROS or subjective section. These are objective findings. You elicited these data through your physical examination of the patient.

Assessment

List both your differential diagnoses and your presumptive diagnosis. Remember that these should be supported by findings in your history and physical exam episodic, comprehensive and alternative soap note example. For a comprehensive exam, you should document at least three ICD code diagnoses.

Plan

Include medications ordered, labs tests, teaching, referrals, and when the patient needs to follow-up. All write-up plans should include documentation of patient education, especially if medication is prescribed and anticipatory guidance. Health maintenance such as screening for breast or colon cancer, should be addressed.

Coding Resource:

All write ups should include the billing codes.  We do not expect you to memorize these codes. You can get them from the billing form that the physician or NPs uses in the office. You can put the billing codes at the end of the write-up.  You should include both the E&M code (level of service) and the ICD-9 diagnosis codes. Your E&M code should be consistent with your patient visit.

MSN Case Write Up Assignment

The purpose of the Case Write- Up Assignment is for your instructor to “see” what you are doing in clinical and “see” how you are making clinical decisions. For these write-ups, you will select a patient seen in your current clinical rotation. You will “write-up” the visit, omitting any identifying patient factors. Ensure your write-ups demonstrate comprehensive advanced practice thinking and not just the new skills of ordering and prescribing.

Make sure to start “fresh”. Do not copy and paste from any examples, templates, other students work or even your own work. Put all your old case write-ups away and give your brain a chance to formulate the note so that it really becomes a part of what you know. THAT will make you a competent NP.

Be honest in your write up. If you realize that you have forgotten to assess something or forgot a certain part of the teaching, just put a note at the bottom of the write-up saying what should have been done. Your clinical faculty do not expect perfect write-ups, but do expect that you use every patient encounter and subsequent write-up as a time to learn and to evaluate and improve your own practice.

 

If your preceptor orders something that is not appropriate or fails to order something that you believe should have been part of the plan, write a note at the end of the write-up to let your instructor know that you are aware and what you would have done. You are not responsible for what your preceptor orders, but you are responsible for knowing the appropriate plan of care and you are responsible for knowing if a plan of care is inappropriate. You and your faculty are the only ones that see the write-up, so no feelings will be hurt. We all get set in our ways and tend to order the same thing over and over. If your readings and research indicate that another plan is more appropriate, write it as an addendum or in parentheses in the plan.

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You are learning to practice evidence-based practice. Support at least one item in the assessment AND plan with research. This can be your textbook and/or other class readings. The best way to support your research is using a research article. Make sure that the article is current (5 years or less old). The article can be used to support the use of the medication (or other therapy) for the presumptive diagnosis. When using an article, please attach the article along with the write-up into the appropriate assignment category. Failure to cite your plan will result in a point penalty reduction (see rubric for additional information)

Note that you CANNOT redo write-ups. A grade cannot be improved by redoing a write up. Faculty will not read and comment on rough draft of write-ups

All case write ups are to be submitted to SafeAssign and the appropriate assignment category by the due date. Failure to submit to SafeAssign will incur a penalty of 5 points per day including weekends (maximum deduction of 25 pt.). Late submissions to the appropriate assignment category will incur a 5pt/day penalty (no maximum) including weekends unless an extension has been requested and approved before the due date episodic, comprehensive and alternative soap note example.

MSN Case Write-Up Rubric

 

Criteria	Exceeds Expectations	Meets Expectations	Below Expectations	No Effort
Chief Complaint (CC)	3 Points Includes CC that includes the reason for visit, is appropriate for the type of write-up AND is in the patient/ family’s own words.	2 Points Includes CC that includes the reason for visit, is appropriate for the type of write-up but is not in the patient/family’s own words	1 Point CC is not appropriate for the type of write-up AND is not in the patient/family’s own words	0 Points  Not included
History of Present Illness (HPI)	10 points Provides a comprehensive HPI that includes all the pertinent information and excludes irrelevant information. HPI is focused and detailed. Does not include any objective data	7 points Provides a HPI that includes pertinent information but misses 1 -2 key components and/or includes information that is irrelevant to the patient visit. HPI is somewhat focused. Does not include objective data.	4 points Provides a superficial HPI that misses 3 or more key components and/or does not include all pertinent information, includes irrelevant information OR includes objective data	0 Points Not included
Medications	3 Points Documents a comprehensive Medication list that includes drug name (brand and generic), dosage, route, frequency and indication. Allergies are documented and includes reaction. Includes NDKA, if applicable.	2 Points Documentation includes medication list but omits 1-2 details. Allergies are documented but does not include reaction.	1 Point Documentation includes medications but omits 3 or more details. Allergies are not documented	0 Points Not included
Pertinent History	10 Points Provides comprehensive past medical history, surgical, family, social, and obstetrical history (when applicable). History is consistent with other documentation. Includes immunization information	7 Points Provides a history but history is superficial AND/OR omits 1 -2 necessary details	4 Points Provides a history but history of superficial and omits 3 or more details	0 Points Not included
Review of Systems	10 Points Complete ROS that addresses each physical system for a comprehensive visit and includes only necessary (but at least 4 systems) for an episodic visit. ROS is completed with a clear narrative. Do not write within normal limit or other variations. If documented abnormalities, states what is considered ‘normal’	7 Points Incomplete ROS that misses 3 or less components for a comprehensive visit OR includes inappropriate systems for an episodic visit	4 Points Incomplete ROS that misses 4 or more components for a comprehensive visit AND/OR includes objective data episodic, comprehensive and alternative soap note example	0 Points  No ROS attempted
Objective Data	20 Points Documents vital signs with documented BMI Documents physical examination: Each system addressed completely for comprehensive exam. Includes only necessary (but at least 4 systems) for an episodic visit. Include pertinent positive and pertinent negative findings. Documents labs, diagnostic tests that are available for that visit.	14 Points  Documents vital signs but is missing BMI Documents an incomplete physical examination: missing 3 or less components for a comprehensive visit and/or missing up to 3 pertinent positives/negatives OR includes unnecessary systems for an episodic visit and/or assesses less than 3 systems Documents labs, diagnostic tests that should be a part of the plan	8 Points Does not document vital signs Documents an incomplete physical examination: missing 4 or more of the components for a comprehensive visit and/ or missing 4 or more pertinent positives/negatives OR Includes unnecessary systems for an episodic visit and/or assesses less than 2 systems Fails to document labs, diagnostic tests	0 Points Not included
Assessment	14 Points Provides 3 or more differential diagnoses and a presumptive diagnosis for an episodic visit. Provides at least 3 diagnoses for a comprehensive visit ICD-9 codes included with each diagnosis	9 Points Provides a presumptive diagnosis but only includes 1-2 differential diagnoses   Does not include ICD-9 codes	4 Points No differential diagnoses OR no presumptive diagnosis	0 Points No differential diagnosis AND no presumptive diagnosis
Plan	20 Points Provides a plan that includes appropriate labs/tests ordered that are pending Includes medications ordered and/or refilled and details about dosing and instructions, and patient teaching are included. Plan includes both pharmacological and non-pharmacological interventions Plan includes referrals and follow up details Orders are appropriate for patient visit. Rationales and citations for sources of interventions Coding and Billing included	14 Points Missing 3 or more components and/or does not include dosing and instructions for medications and/or does not include Coding and Billing	8 Points Missing 4 or more of the required components OR Plan is not supported by evidence and citations for sources of intervention are missing AND Does not include Coding and Billing	0 Points Not included or inappropriate to patient visit
Formatting/APA	10 Points No errors in  grammar and spelling . No errors in APA format Write-up is in proper format and adheres to the appropriate page limits.	7 Points Up to 3 spelling or grammar errors OR 3 APA errors Write-up is in proper format and adheres to the appropriate page limits	4 Points Up to 3 errors in spelling and/ or grammar AND/OR APA errors AND Write-up is not in proper format OR does not adhere to the appropriate page limits episodic, comprehensive and alternative soap note example	0 Points 4 or more errors in spelling and/or grammar AND/OR 4 or more APA errors