Episodic, Comprehensive, and Alternative SOAP Note Example

Episodic, Comprehensive, and Alternative SOAP Note Example

Episodic Write-up: Episodic visits typically involve single-time encounters with the possibility of a short follow-up, depending on the diagnosis and existing comorbidities. These encounters are occasional and focus on the affected body system(s). Examples include conditions like upper respiratory infections (URIs), bronchitis, seasonal allergic rhinitis, acute pharyngitis, acute gastroenteritis, pneumonia, and contact dermatitis, among others.

NRS-429VN Family-Centered Health Promotion Topic 1 Discussion Question 1

This write-up should be 2-4 pages, single-spaced, and concentrate on the most pertinent information. It does not encompass all the systems or sections found in a comprehensive write-up, only those relevant to the specific case. This approach helps streamline the use of essential tools and information, supporting critical thinking.

Comprehensive Write-up: Comprehensive visits often require thorough assessments that cover the entire body, extensive review of systems (ROS), and a detailed physical examination (PE). Visits that may necessitate comprehensive ROS, PE, and write-up include annual physicals, well-woman exams (which may not always be head-to-toe but often constitute essential preventive care for women), well-child exams, visits for new or established patients with complex or chronic diseases, non-specific complaints like fatigue, generalized weakness, body aches, dizziness, and more. This episodic, comprehensive, and alternative SOAP note example should be 5-8 pages, single-spaced.

It’s crucial to differentiate between episodic and comprehensive visits. Conducting a comprehensive examination when an episodic visit or write-up is warranted can confuse both the provider and the patient, potentially wasting time. Such practice may undermine the patient’s trust in the provider’s clinical judgment. It’s important to note that insurance reimbursement doesn’t increase based on the decision to complete a comprehensive note for an episodic visit or diagnosis.

Alternative Write-up: Some courses may require specialized write-ups based on patient demographics or specific disease processes. These write-ups adhere to the same guidelines as comprehensive write-ups.

Case Write-up Outline

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

Subjective:

Chief Complaint (CC): The patient’s chief complaint should be enclosed in quotation marks, e.g., “I’ve had a cough and sore throat for 2 days.”

History of Present Illness (HPI): This is a crucial part of the assessment. It involves asking pertinent questions to gain a comprehensive understanding of the patient’s condition, using frameworks like OLD CARTS or PQRST. Even as you become more proficient in physical exams and lab testing, the HPI remains of utmost importance, as it contributes to diagnostic reasoning.

Past Medical History: Document past or present illnesses, being cautious not to blindly copy history from prior clinical notes.

Past Surgical History: Include past surgeries, approximate dates, and also note any traumas or hospitalizations.

Medications: List medication names, doses, frequencies, and indications (the reason for taking them). Do not omit the indication, and be sure to include PRN medications and their dosing frequency. This helps ensure all important information is captured in the patient history.

Allergies: Document medication allergies and, if applicable, food allergies.

Social History: Include information such as alcohol and cigarette use, sexual history, work history, and health-promoting activities like exercise and immunizations. Specificity is key; avoid vague terms like “UTD” (up to date) for immunizations. For children, provide dates for all immunizations.

Family History: Typically, include information spanning at least two generations.

Obstetrical History: Include relevant information when applicable, such as the number of pregnancies.

Review of Systems (ROS): For comprehensive visits, the ROS should be extensive, covering all body systems. For episodic visits, tailor the ROS to the likely differential diagnosis list. Always address growth and development in pediatric patients, and for childbearing women, document the date of the last menstrual period (LMP) and contraceptive methods used in every visit.

Objective

Vital Signs (BMI should be included in every visit)

Physical Examination

Laboratory Data, Diagnostic Tests, Imaging: Include available data at the time of the visit. Do not include tests ordered during the visit if results are not yet available.

TIP:

Distinguish clearly between subjective and objective data. Subjective data come from patient interviews, family, or significant others. This encompasses data from the chief complaint, social/family history, and ROS. Objective data result from physical examination, vital signs, and diagnostic test results. Statements like “Denies chest pain, SOB, dysuria, vaginal bleeding, diarrhea, etc.” belong in the subjective section (ROS) and not in the PE section. Objective findings, such as “Alert and oriented; no tenderness; no erythema; breath sounds clear; no spine curvature,” result from the physical examination and should be placed in the PE section.

Assessment

List both differential diagnoses and the presumptive diagnosis, supported by findings from the history and physical exam. For a comprehensive exam, document at least three ICD code diagnoses.

Plan

Include medications prescribed, ordered lab tests, patient education, referrals, and the recommended follow-up schedule. All write-up plans should incorporate patient education, especially when prescribing medication and providing anticipatory guidance. Health maintenance, such as cancer screenings for breast or colon cancer, should also be addressed.

Coding Resource:

Include billing codes in all write-ups. You can find these codes on the billing form used by physicians or nurse practitioners in the office. Place the billing codes at the end of the write-up, including both the E&M code (level of service) and the ICD-9 diagnosis codes. Ensure consistency between your E&M code and the patient visit.

MSN Case Write-Up Assignment

The purpose of the Case Write-Up Assignment is for your instructor to assess your clinical performance and decision-making. In these write-ups, select a patient from your current clinical rotation while excluding any identifying patient details. Ensure that your write-ups demonstrate advanced practice thinking and not just the application of new skills like ordering and prescribing.

Start each write-up from scratch and avoid copying from examples, templates, other students’ work, or your previous write-ups. Give yourself the opportunity to formulate each note independently, internalizing the knowledge and skills.

Be transparent in your write-up. If you realize that you missed assessing something or forgot to include certain teaching points, acknowledge it in a note at the end of the write-up. Your

clinical faculty does not expect flawless write-ups but does expect you to use each patient encounter and subsequent write-up as an opportunity for learning and self-improvement.

If your preceptor orders something inappropriate or overlooks a necessary component of the plan, include a note at the end of the write-up to inform your instructor that you are aware of the issue and what you would have done differently. You are not responsible for your preceptor’s orders, but you are responsible for understanding the appropriate plan of care and recognizing when it is inappropriate. The write-up is seen only by you and your faculty, so there is no need to worry about hurting anyone’s feelings. Healthcare providers sometimes establish routines and tend to order the same treatments repeatedly. If your research suggests a more suitable plan, include it as an addendum or in parentheses in the plan section.

You are learning to practice evidence-based medicine. Support at least one item in the assessment and plan with research, preferably a research article. Ensure the article is current (within the last 5 years). Using a research article to support medication use (or other therapy) for the presumptive diagnosis is effective. Attach the article along with the write-up in the appropriate assignment category. Failure to cite your plan will result in a reduction in points (see rubric for details).

Please note that you cannot revise or redo write-ups. Your grade cannot be improved by resubmitting a write-up. Faculty will not review or comment on rough drafts of write-ups.

All case write-ups should be submitted to SafeAssign and the appropriate assignment category by the due date. Failure to submit to SafeAssign will result in a penalty of 5 points per day, including weekends (maximum deduction of 25 points). Late submissions to the assignment category will incur a penalty of 5 points per day, with no maximum, including weekends, unless an extension has been requested and approved before the due date.