the soap note is template form the reference page APA only Patient Information:Initials, Age, Sex, RaceS.CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patientâ€™s own words – for instance “headache”, NOT “bad headache for 3 daysâ€.HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was â€œheadacheâ€, the LOCATES for the HPI might look like the following example:Location: headOnset: 3 days agoCharacter: pounding, pressure around the eyes and templesAssociated signs and symptoms: nausea, vomiting, photophobia, phonophobiaTiming: after being on the computer all day at workExacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely betterSeverity: 7/10 pain scaleCurrent 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 (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).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 neededSoc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current 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, living environment, text/cell phone use while driving, and support system.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: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.Example of Complete ROS:GENERAL: 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.Case 3: Focused Ear Exam Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked. He has complained to her about a mild earache for the past two days. His grandmother believes that he feels warm but did not verify this with a thermometer. James states that the pain was worse while he was falling asleep and that it was harder for him to hear. When you begin basic assessments, you notice that James has a prominent tan. When you ask him how he’s been spending his summer, James responds that he’s been spending a lot of time in the pool.Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.
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