Executive Solution Overview
Rwh 2 soap notes **files (1)** – ## 1SOAPNoteTemplate-Final1_12417645411.pdf **## 1SOAPNoteTemplate-Final1_12417645411.pdf** SOAP Note NU : Herzing University Name: Typhon Encounter #: Comprehensive: Focused: S: SUBJECTIVE DATA CC: The patient reported that she has been having a worse memory and f…
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Rwh 2 soap notes
**files (1)**
– ## 1SOAPNoteTemplate-Final1_12417645411.pdf
**## 1SOAPNoteTemplate-Final1_12417645411.pdf**
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
S: SUBJECTIVE DATA
CC: The patient reported that she has been having a worse memory and forgetting
things, which is confirmed by her daughter.
HPI: History: The problems with memory started about one year ago and have become
increasingly severe.
Location: Cognitive/memory capability.
Time:Ongoing throughout the last year with slow development.
Characteristics: Becoming forgetful more often, asking the same questions and
losing things.
Related Factors: Daughter informs that patient experiences difficulties
remembering the recent conversations and appointments.
Relieving Factors: No relief is of consequence.
Treatment: No previous pharmacologic pre-visit treatment.
Summary: A 72-year-old female was admitted with progressive memory decline
during a 1-year time period that was associated with forgetfulness, repetitive
questioning, and the loss of or misplaced items.
PMH: Hypertension (was diagnosed 10 years ago), hyperlipidemia. No major surgeries
reported.
ALLERGIES NKDA
MEDICATIONS Donepezil 5 mg PO daily as a memory loss intervention.
SH Retired teacher. Lives with daughter. Denies smoking or illicit drug use.
Occasional alcohol use. No economic obstacles reported.
FH In late 70s, mother was diagnosed as having dementia. Father died when he was 80
years old because of heart attack.
HEALTH
PROMOTION &
MAINTENANCE
Patient denies severe physical exercise, walks daily. Balanced diet reported.
Vaccinations are current with influenza vaccine. Examined eyes previously last
year.
ROS
(put N/A in sections
not completed day of
exam)
Constitutional Denies fever, fatigue.
Head No headaches.
Eyes No visual changes.
Ears, Nose, Mouth, Throat No hearing loss and throat pain.
Neck No stiffness.
Cardiovascular/Peripheral
Vascular
Denies cardiac pain or palpitations.
Respiratory Denies dyspnea.
Breast
Gastrointestinal No vomit, nausea.
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
Genitourinary N/A
Musculoskeletal No joint pains.
Integumentary No rashes.
Neurological Denies forgetfulness and loss of memory.
Psychiatric (screening tools: Ex:
PHQ-9, MMSE, GAD-7)
Mild cognitive impairment observed.
Endocrine Denies being intolerant to cold or heat.
Hematologic/Lymphatic No bruising or bleeding.
Allergic/Immunologic NKDA.
Other N/A
O: OBJECTIVE DATA
VITALS: HR:76 RR:16 BP:126/76 Temp: 98.4°F
SpO2%: 98% Ht: 5’4’ Wt: 150 lb BMI:25.7
Age:72 LMP: PAIN:0/10
PHYSICAL
EXAM
(Pertinent data
related to
presenting
problem or
visit type. Put
N/A in sections
not completed
day of exam)
General Appearance Observed alert, cooperative, mild impairment
of memory.
Head Normocephalic, atraumatic.
Eyes PERRLA.
ENT, Mouth Oral mucosa moist.
Neck Soft, with no lymph node.
Cardiovascular/Peripheral Vascular Normally high rate and beat.
Respiratory Clear bilaterally.
Breast
Gastrointestinal soft abdomen, non-tender.
Genitourinary Male
• External Exam N/A
• Internal Exam N/A
Genitourinary Female
• External Exam N/A
• Internal Exam N/A
Musculoskeletal the gait is normal.
Integumentary N/A
Neurological It is alert, person and place oriented and short
term memory is impaired.
Psychiatric Right mood, impaired memory slightly.
Endocrine N/A
Hematologic/Lymphatic N/A
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
Allergic/Immunologic N/A
Other N/A
A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS ICD-10 CODES
PRIORITIZE
DIAGNOSIS
1. Alzheimer's disease ICD-10: G30.9
2.
3.
VISIT CODES CPT BILLING CODES CPT-9: 99213
DIAGNOSTICS POC TESTING CPT-10: 99203
TESTS REVIEWED Mental examination screening (MMSE
recommended).
P: PLAN
ACTIONS 1.
Diagnosis: Alzheimer's disease
Diagnostics Order:
Cognitive evaluation (MMSE), regular laboratory tests to exclude metabolic
factors.
Therapeutic:
Donepezil 5 mg PO on a daily basis, #30 tablets, 2 refills.
Education:
Management of medication adherence, routine relevance, memory aid and
caregiver assistance were discussed. Offered home safety advice such as
medication organizers and elimination of risks.
Consultation/Collaboration:
Referral to the neurology department to evaluate and manage cognition.
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
2. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
3. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
PREVENTITIVE
(Used for
comprehensive exams)
Enter Guidance, Health Promotion, and/or Disease Prevention for
patient, family, and/or caregiver.
FOLLOW UP Repeat visit after 3 months or earlier in case of worsening of symptoms.
**## 1SOAPNoteTemplate-Final1_12417645411.pdf**
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
S: SUBJECTIVE DATA
CC: The patient reported that she has been having a worse memory and forgetting
things, which is confirmed by her daughter.
HPI: History: The problems with memory started about one year ago and have become
increasingly severe.
Location: Cognitive/memory capability.
Time:Ongoing throughout the last year with slow development.
Characteristics: Becoming forgetful more often, asking the same questions and
losing things.
Related Factors: Daughter informs that patient experiences difficulties
remembering the recent conversations and appointments.
Relieving Factors: No relief is of consequence.
Treatment: No previous pharmacologic pre-visit treatment.
Summary: A 72-year-old female was admitted with progressive memory decline
during a 1-year time period that was associated with forgetfulness, repetitive
questioning, and the loss of or misplaced items.
PMH: Hypertension (was diagnosed 10 years ago), hyperlipidemia. No major surgeries
reported.
ALLERGIES NKDA
MEDICATIONS Donepezil 5 mg PO daily as a memory loss intervention.
SH Retired teacher. Lives with daughter. Denies smoking or illicit drug use.
Occasional alcohol use. No economic obstacles reported.
FH In late 70s, mother was diagnosed as having dementia. Father died when he was 80
years old because of heart attack.
HEALTH
PROMOTION &
MAINTENANCE
Patient denies severe physical exercise, walks daily. Balanced diet reported.
Vaccinations are current with influenza vaccine. Examined eyes previously last
year.
ROS
(put N/A in sections
not completed day of
exam)
Constitutional Denies fever, fatigue.
Head No headaches.
Eyes No visual changes.
Ears, Nose, Mouth, Throat No hearing loss and throat pain.
Neck No stiffness.
Cardiovascular/Peripheral
Vascular
Denies cardiac pain or palpitations.
Respiratory Denies dyspnea.
Breast
Gastrointestinal No vomit, nausea.
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
Genitourinary N/A
Musculoskeletal No joint pains.
Integumentary No rashes.
Neurological Denies forgetfulness and loss of memory.
Psychiatric (screening tools: Ex:
PHQ-9, MMSE, GAD-7)
Mild cognitive impairment observed.
Endocrine Denies being intolerant to cold or heat.
Hematologic/Lymphatic No bruising or bleeding.
Allergic/Immunologic NKDA.
Other N/A
O: OBJECTIVE DATA
VITALS: HR:76 RR:16 BP:126/76 Temp: 98.4°F
SpO2%: 98% Ht: 5’4’ Wt: 150 lb BMI:25.7
Age:72 LMP: PAIN:0/10
PHYSICAL
EXAM
(Pertinent data
related to
presenting
problem or
visit type. Put
N/A in sections
not completed
day of exam)
General Appearance Observed alert, cooperative, mild impairment
of memory.
Head Normocephalic, atraumatic.
Eyes PERRLA.
ENT, Mouth Oral mucosa moist.
Neck Soft, with no lymph node.
Cardiovascular/Peripheral Vascular Normally high rate and beat.
Respiratory Clear bilaterally.
Breast
Gastrointestinal soft abdomen, non-tender.
Genitourinary Male
• External Exam N/A
• Internal Exam N/A
Genitourinary Female
• External Exam N/A
• Internal Exam N/A
Musculoskeletal the gait is normal.
Integumentary N/A
Neurological It is alert, person and place oriented and short
term memory is impaired.
Psychiatric Right mood, impaired memory slightly.
Endocrine N/A
Hematologic/Lymphatic N/A
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
Allergic/Immunologic N/A
Other N/A
A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS ICD-10 CODES
PRIORITIZE
DIAGNOSIS
1. Alzheimer's disease ICD-10: G30.9
2.
3.
VISIT CODES CPT BILLING CODES CPT-9: 99213
DIAGNOSTICS POC TESTING CPT-10: 99203
TESTS REVIEWED Mental examination screening (MMSE
recommended).
P: PLAN
ACTIONS 1.
Diagnosis: Alzheimer's disease
Diagnostics Order:
Cognitive evaluation (MMSE), regular laboratory tests to exclude metabolic
factors.
Therapeutic:
Donepezil 5 mg PO on a daily basis, #30 tablets, 2 refills.
Education:
Management of medication adherence, routine relevance, memory aid and
caregiver assistance were discussed. Offered home safety advice such as
medication organizers and elimination of risks.
Consultation/Collaboration:
Referral to the neurology department to evaluate and manage cognition.
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
2. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
3. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
PREVENTITIVE
(Used for
comprehensive exams)
Enter Guidance, Health Promotion, and/or Disease Prevention for
patient, family, and/or caregiver.
FOLLOW UP Repeat visit after 3 months or earlier in case of worsening of symptoms.