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Asked by BaronDiscoveryCoyote16

Construct a preventative screening visit scenario for a patient in one of the phases of life discussed (i.e., adolescent, early adulthood, midlife, perimenopausal, or postmenopausal) Write your note in SOAP format. Ensure that your assessment is developmentally appropriate as well as any testing, screening, or diagnostics that you order. Discuss health promotion and disease prevention as appropriate. Do not replicate your peer’s patient typeSOAP Note:

SOAP FORMAT

 

 

Patient / Client initials:

 

Age:                                      
Gender:                 Ethnicity:                           

 

SUBJECTIVE DATA

Chief Complaint (CC)

 

History of Present Illness (HPI)

 

Past Medical History (PMH)

 

Past Surgical

History (PSH)

 

Immunization

status

 

Medications

 

Allergies

 

Family History (FH)

 

Psychosocial or

Social History (SH)

 

 

 

 

Nutritional

Screening if applicable

 

Advanced Directives if

applicable

 

 

Review of Systems (ROS)

 

Constitutional

 

 

 

 

 

Eyes, Ears, Nose Throat/Mouth

 

Cardiovascular

 

Respiratory

 

Gastrointestinal

 

Genitourinary

 

Integumentary

 

 

 

 

Musculoskeletal

 

Neurological

 

 

Psychiatric

 

 

 

Endocrine

 

 

Hematologic

/Lymphatic

 

 

Immune function / dysfunction

 

 

 

 

OBJECTIVE DATA

 

 

 

 

Vital Signs

 

HEENT

 

Neck

 

Respiratory

 

Cardiovascular

 

Gastrointestinal

 

Genitourinary

 

Musculoskeletal

 

Integumentary

 

Psychiatric

 

Neurological

 

 

 

 

ASSESSMENT: DIFFERENTIAL DIAGNOSES AND SUPPORTING DATA

 

3-5

differential diagnoses for each presenting problem

Data in your findings that support

this diagnosis

Data in your findings that rule out this diagnosis

Citation of evidence for accepting or rejecting the diagnosis

   

 

 

     

 

   

 

 

     

 

 

 

Final ICD 10 diagnosis codes for the current visit

 

ICD 10

Code

Corresponding Diagnosis
   

 

 

 

 

 

 

PLAN: TREATMENT PLAN

 

Additional diagnostic tests needed

 

Treatments:

Pharmacological

 

Treatments: Non- Pharmacological

 

Patient Education

 

Consultations recommended with rationale

 

Disposition

 

 

 

 

CPT Billing Codes Reflected in the Treatment Plan

 

CPT Code Corresponding Diagnosis
   
   
   

 

 

Referenc

SCIENCE
HEALTH SCIENCE
NURSING
NRSG 656

 

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