Executive Solution Overview
Rw 2 soaps **files (1)** – ## SOAPNoteTemplateonly5.docx **## SOAPNoteTemplateonly5.docx** | | | | — | — | | **SOAP Note _______**<br>NU___:_________<br>Herzing University | **Name:_________________________**<br>Typhon Encounter #: __________…
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Rw 2 soaps
**files (1)**
– ## SOAPNoteTemplateonly5.docx
**## SOAPNoteTemplateonly5.docx**
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| **SOAP Note _______**<br>NU___:_________<br>Herzing University | **Name:_________________________**<br>Typhon Encounter #: _____________________<br>**Comprehensive:____Focused:____** |
| | | |
| — | — | — |
| S: SUBJECTIVE DATA |
| CC: | “I experience chest pain on walking which disappears when I rest. |
| HPI: | 77 years of age white male with a history of CAD with complaints of a chest discomfort during exertion. O: Gradual onset over weeks. L: Substernal. D: Exertional in nature, lasts 5-10 minutes. C: Pressure-like discomfort. A: Occupying because of walking uphill. R: Relieved by rest. T: No nitroglycerin in the house. S: Stable angina symptoms. |
| PMH: | Coronary artery disease. |
| ALLERGIES | NKDA |
| MEDICATIONS | Aspirin 81mg daily (per history). |
| SH | Former smoker. Lives with spouse. |
| FH | Father deceased from MI at 70. |
| HEALTH PROMOTION & MAINTENANCE | Cardiac diet advised, frequent cardiology follow-up prescribed. |
| ROS <br>(put N/A in sections not completed day of exam) | Constitutional | N/A |
| | Head | N/A |
| | Eyes | N/A |
| | Ears, Nose, Mouth, Throat | N/A |
| | Neck | N/A |
| | Cardiovascular/Peripheral Vascular | Affirmative of exertional chest pain. |
| | Respiratory | Denies SOB at rest. |
| | Breast | N/A |
| | Gastrointestinal | N/A |
| | Genitourinary | N/A |
| | Musculoskeletal | N/A |
| | Integumentary | N/A |
| | Neurological | N/A |
| | Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) | N/A |
| | Endocrine | N/A |
| | Hematologic/Lymphatic | N/A |
| | Allergic/Immunologic | N/A |
| | Other | N/A |
| | | | | |
| — | — | — | — | — |
| O: OBJECTIVE DATA |
| VITALS: | HR: 82 | RR: 18 | BP: 138/84 | Temp: 98.6 o C |
| | SpO2%: 97 | Ht: | Wt: | BMI: 27 |
| | Age: 77 | LMP: | PAIN:5/10 | |
| PHYSICAL EXAM <br> <br>(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam) | General Appearance | No distress during rest, alert. |
| | Head | N/A |
| | Eyes | N/A |
| | ENT, Mouth | N/A |
| | Neck | N/A |
| | Cardiovascular/Peripheral Vascular | Normally fast/regular, no murmurs. |
| | Respiratory | Clear bilaterally. |
| | Breast | N/A |
| | Gastrointestinal | N/A |
| | Genitourinary Male |
| | · External Exam | N/A |
| | · Internal Exam | N/A |
| | Genitourinary Female |
| | · External Exam | N/A |
| | · Internal Exam | N/A |
| | Musculoskeletal | N/A |
| | Integumentary | N/A |
| | Neurological | N/A |
| | Psychiatric | N/A |
| | Endocrine | N/A |
| | Hematologic/Lymphatic | N/A |
| | Allergic/Immunologic | N/A |
| | Other | N/A |
| | | |
| — | — | — |
| A: ASSESSMENT AND DIAGNOSIS |
| | DIAGNOSIS | ICD-10 CODES |
| PRIORITIZE DIAGNOSIS | 1. Angina pectoris | ICD-10: I20.9 (ICD-9: 413.9) |
| | 2. | |
| | 3. | |
| | | | |
| — | — | — | — |
| VISIT CODES | | CPT BILLING CODES | 99214 (established);<br>CPT 99204 (new). |
| DIAGNOSTICS | | POC TESTING | |
| | | TESTS REVIEWED | |
| | | |
| — | — | — |
| P: PLAN |
| ACTIONS | 1. | Diagnosis: Stable Angina<br>Diagnostics Order: EKG now; referral to stress test.<br>Therapeutic: Nitroglycerin 0.4 mg SL tablet, 1 tablet at a time every 5 minutes PRN chest pain up to 3 doses, #25, 1 refill.<br>Education: Take nitroglycerin when the pain occurs; call 911 when pain does not lessen after 3 doses. Examined heart warning signs.<br>Consultation/Collaboration: Cardiology referral. |
| | 2. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
| | 3. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
| PREVENTITIVE <br> <br>(Used for comprehensive exams) | | |
| FOLLOW UP | | 1 month or earlier in case of increasing symptoms. |
**## SOAPNoteTemplateonly5.docx**
| | |
| — | — |
| **SOAP Note _______**<br>NU___:_________<br>Herzing University | **Name:_________________________**<br>Typhon Encounter #: _____________________<br>**Comprehensive:____Focused:____** |
| | | |
| — | — | — |
| S: SUBJECTIVE DATA |
| CC: | “I experience chest pain on walking which disappears when I rest. |
| HPI: | 77 years of age white male with a history of CAD with complaints of a chest discomfort during exertion. O: Gradual onset over weeks. L: Substernal. D: Exertional in nature, lasts 5-10 minutes. C: Pressure-like discomfort. A: Occupying because of walking uphill. R: Relieved by rest. T: No nitroglycerin in the house. S: Stable angina symptoms. |
| PMH: | Coronary artery disease. |
| ALLERGIES | NKDA |
| MEDICATIONS | Aspirin 81mg daily (per history). |
| SH | Former smoker. Lives with spouse. |
| FH | Father deceased from MI at 70. |
| HEALTH PROMOTION & MAINTENANCE | Cardiac diet advised, frequent cardiology follow-up prescribed. |
| ROS <br>(put N/A in sections not completed day of exam) | Constitutional | N/A |
| | Head | N/A |
| | Eyes | N/A |
| | Ears, Nose, Mouth, Throat | N/A |
| | Neck | N/A |
| | Cardiovascular/Peripheral Vascular | Affirmative of exertional chest pain. |
| | Respiratory | Denies SOB at rest. |
| | Breast | N/A |
| | Gastrointestinal | N/A |
| | Genitourinary | N/A |
| | Musculoskeletal | N/A |
| | Integumentary | N/A |
| | Neurological | N/A |
| | Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) | N/A |
| | Endocrine | N/A |
| | Hematologic/Lymphatic | N/A |
| | Allergic/Immunologic | N/A |
| | Other | N/A |
| | | | | |
| — | — | — | — | — |
| O: OBJECTIVE DATA |
| VITALS: | HR: 82 | RR: 18 | BP: 138/84 | Temp: 98.6 o C |
| | SpO2%: 97 | Ht: | Wt: | BMI: 27 |
| | Age: 77 | LMP: | PAIN:5/10 | |
| PHYSICAL EXAM <br> <br>(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam) | General Appearance | No distress during rest, alert. |
| | Head | N/A |
| | Eyes | N/A |
| | ENT, Mouth | N/A |
| | Neck | N/A |
| | Cardiovascular/Peripheral Vascular | Normally fast/regular, no murmurs. |
| | Respiratory | Clear bilaterally. |
| | Breast | N/A |
| | Gastrointestinal | N/A |
| | Genitourinary Male |
| | · External Exam | N/A |
| | · Internal Exam | N/A |
| | Genitourinary Female |
| | · External Exam | N/A |
| | · Internal Exam | N/A |
| | Musculoskeletal | N/A |
| | Integumentary | N/A |
| | Neurological | N/A |
| | Psychiatric | N/A |
| | Endocrine | N/A |
| | Hematologic/Lymphatic | N/A |
| | Allergic/Immunologic | N/A |
| | Other | N/A |
| | | |
| — | — | — |
| A: ASSESSMENT AND DIAGNOSIS |
| | DIAGNOSIS | ICD-10 CODES |
| PRIORITIZE DIAGNOSIS | 1. Angina pectoris | ICD-10: I20.9 (ICD-9: 413.9) |
| | 2. | |
| | 3. | |
| | | | |
| — | — | — | — |
| VISIT CODES | | CPT BILLING CODES | 99214 (established);<br>CPT 99204 (new). |
| DIAGNOSTICS | | POC TESTING | |
| | | TESTS REVIEWED | |
| | | |
| — | — | — |
| P: PLAN |
| ACTIONS | 1. | Diagnosis: Stable Angina<br>Diagnostics Order: EKG now; referral to stress test.<br>Therapeutic: Nitroglycerin 0.4 mg SL tablet, 1 tablet at a time every 5 minutes PRN chest pain up to 3 doses, #25, 1 refill.<br>Education: Take nitroglycerin when the pain occurs; call 911 when pain does not lessen after 3 doses. Examined heart warning signs.<br>Consultation/Collaboration: Cardiology referral. |
| | 2. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
| | 3. | Diagnosis:<br>Diagnostics Order:<br>Therapeutic:<br>Education:<br>Consultation/Collaboration: |
| PREVENTITIVE <br> <br>(Used for comprehensive exams) | | |
| FOLLOW UP | | 1 month or earlier in case of increasing symptoms. |
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