Assignment Prompt & Instructions
Need soap note asap
– ## NU611WeeklySOAPnoteinstructionsWeeks234-rev32023.docx
– ## SOAPNoteTemplate-Final.docx
**## NU611WeeklySOAPnoteinstructionsWeeks234-rev32023.docx**
Over the course of the semester you will choose 1 patient encounter each week to document an extended SOAP note for. In Weeks 2, 3, and 4, you will submit only the subjective and objective data sets for your chosen encounter.
It is expected that you vary the primary focus of each note to ensure you are receiving quality feedback for several types of patient encounters to include acute, chronic and wellness encounters. You are not to utilize the same type of encounter, acute/chronic health condition or wellness exam, more than once unless you have received approval to do so from your clinical faculty person.
Each SOAP note carries a 30-point value.
SOAP notes will be evaluated using a standardized rubric. Please review the evaluation criterion to ensure that your SOAP notes are constructed to address the required elements and desired level of achievement.
For planned weekly clinical experiences submission of the SOAP notes would be accomplished by submitting one SOAP note weekly for weeks 2 through week 7.
For planned and approved condensed, compressed or alternate clinical experiences, submission of the SOAP note would be dependent on the approved clinical schedule. This may mean that more than 1 SOAP note would need to be submitted on a weekly basis. If you are not in clinical for weeks where a SOAP note is due a ‘0’ will be input into the Grade Center as a place holder until you have submitted the required assignment.
**## SOAPNoteTemplate-Final.docx**
| | |
| — | — |
| **SOAP Note _______**<br>NU___:_________<br>Herzing University | **Name:_________________________**<br>Typhon Encounter #: _____________________<br>**Comprehensive:____Focused:____** |
| | | |
| — | — | — |
| S: SUBJECTIVE DATA |
| CC: | What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased. |
| HPI: | Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary] |
| PMH: | This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. |
| ALLERGIES | State the offending medication/food and the reactions. |
| MEDICATIONS | Names, dosages, and routes of administration along with indication of use. |
| SH | Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. |
| FH | Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known. |
| HEALTH PROMOTION & MAINTENANCE | **Required for all SOAP notes:** Immunizations, exercise, diet, etc. Remember to use the <br>[United States Clinical Preventative Services Task Force (USPSTF)](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams. |
| ROS <br>(put N/A in sections not completed day of exam) | Constitutional | |
| | Head | |
| | Eyes | |
| | Ears, Nose, Mouth, Throat | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |
| | | | | |
| — | — | — | — | — |
| O: OBJECTIVE DATA |
| VITALS: | HR: | RR: | BP: | Temp: |
| | SpO2%: | Ht: | Wt: | BMI: |
| | Age: | LMP: | PAIN: | |
| 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 | |
| | Head | |
| | Eyes | |
| | ENT, Mouth | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary Male |
| | · External Exam | |
| | · Internal Exam | |
| | Genitourinary Female |
| | · External Exam | |
| | · Internal Exam | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |
| | | |
| — | — | — |
| A: ASSESSMENT AND DIAGNOSIS |
| | DIAGNOSIS | ICD-10 CODES |
| PRIORITIZE DIAGNOSIS | 1. | |
| | 2. | |
| | 3. | |
| | | | |
| — | — | — | — |
| VISIT CODES | | CPT BILLING CODES | |
| DIAGNOSTICS | | POC TESTING | |
| | | TESTS REVIEWED | |
| | | |
| — | — | — |
| P: PLAN |
| ACTIONS | 1. | Diagnosis: <br>Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)<br>Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)<br>Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.<br>Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning. |
| | 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) | | Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver. |
| FOLLOW UP | | |
**## SOAPNoteTemplate-Final.docx**
| | |
| — | — |
| **SOAP Note _______**<br>NU___:_________<br>Herzing University | **Name:_________________________**<br>Typhon Encounter #: _____________________<br>**Comprehensive:____Focused:____** |
| | | |
| — | — | — |
| S: SUBJECTIVE DATA |
| CC: | What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased. |
| HPI: | Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary] |
| PMH: | This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. |
| ALLERGIES | State the offending medication/food and the reactions. |
| MEDICATIONS | Names, dosages, and routes of administration along with indication of use. |
| SH | Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. |
| FH | Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known. |
| HEALTH PROMOTION & MAINTENANCE | **Required for all SOAP notes:** Immunizations, exercise, diet, etc. Remember to use the <br>[United States Clinical Preventative Services Task Force (USPSTF)](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams. |
| ROS <br>(put N/A in sections not completed day of exam) | Constitutional | |
| | Head | |
| | Eyes | |
| | Ears, Nose, Mouth, Throat | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |
| | | | | |
| — | — | — | — | — |
| O: OBJECTIVE DATA |
| VITALS: | HR: | RR: | BP: | Temp: |
| | SpO2%: | Ht: | Wt: | BMI: |
| | Age: | LMP: | PAIN: | |
| 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 | |
| | Head | |
| | Eyes | |
| | ENT, Mouth | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary Male |
| | · External Exam | |
| | · Internal Exam | |
| | Genitourinary Female |
| | · External Exam | |
| | · Internal Exam | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |
| | | |
| — | — | — |
| A: ASSESSMENT AND DIAGNOSIS |
| | DIAGNOSIS | ICD-10 CODES |
| PRIORITIZE DIAGNOSIS | 1. | |
| | 2. | |
| | 3. | |
| | | | |
| — | — | — | — |
| VISIT CODES | | CPT BILLING CODES | |
| DIAGNOSTICS | | POC TESTING | |
| | | TESTS REVIEWED | |
| | | |
| — | — | — |
| P: PLAN |
| ACTIONS | 1. | Diagnosis: <br>Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)<br>Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)<br>Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.<br>Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning. |
| | 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) | | Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver. |
| FOLLOW UP | | |
**## NU611WeeklySOAPnoteinstructionsWeeks234-rev32023.docx**
Over the course of the semester you will choose 1 patient encounter each week to document an extended SOAP note for. In Weeks 2, 3, and 4, you will submit only the subjective and objective data sets for your chosen encounter.
It is expected that you vary the primary focus of each note to ensure you are receiving quality feedback for several types of patient encounters to include acute, chronic and wellness encounters. You are not to utilize the same type of encounter, acute/chronic health condition or wellness exam, more than once unless you have received approval to do so from your clinical faculty person.
Each SOAP note carries a 30-point value.
SOAP notes will be evaluated using a standardized rubric. Please review the evaluation criterion to ensure that your SOAP notes are constructed to address the required elements and desired level of achievement.
For planned weekly clinical experiences submission of the SOAP notes would be accomplished by submitting one SOAP note weekly for weeks 2 through week 7.
For planned and approved condensed, compressed or alternate clinical experiences, submission of the SOAP note would be dependent on the approved clinical schedule. This may mean that more than 1 SOAP note would need to be submitted on a weekly basis. If you are not in clinical for weeks where a SOAP note is due a ‘0’ will be input into the Grade Center as a place holder until you have submitted the required assignment.
**## SOAPNoteTemplate-Final.docx**
| | |
| — | — |
| **SOAP Note _______**<br>NU___:_________<br>Herzing University | **Name:_________________________**<br>Typhon Encounter #: _____________________<br>**Comprehensive:____Focused:____** |
| | | |
| — | — | — |
| S: SUBJECTIVE DATA |
| CC: | What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased. |
| HPI: | Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary] |
| PMH: | This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. |
| ALLERGIES | State the offending medication/food and the reactions. |
| MEDICATIONS | Names, dosages, and routes of administration along with indication of use. |
| SH | Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. |
| FH | Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known. |
| HEALTH PROMOTION & MAINTENANCE | **Required for all SOAP notes:** Immunizations, exercise, diet, etc. Remember to use the <br>[United States Clinical Preventative Services Task Force (USPSTF)](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams. |
| ROS <br>(put N/A in sections not completed day of exam) | Constitutional | |
| | Head | |
| | Eyes | |
| | Ears, Nose, Mouth, Throat | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |
| | | | | |
| — | — | — | — | — |
| O: OBJECTIVE DATA |
| VITALS: | HR: | RR: | BP: | Temp: |
| | SpO2%: | Ht: | Wt: | BMI: |
| | Age: | LMP: | PAIN: | |
| 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 | |
| | Head | |
| | Eyes | |
| | ENT, Mouth | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary Male |
| | · External Exam | |
| | · Internal Exam | |
| | Genitourinary Female |
| | · External Exam | |
| | · Internal Exam | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |
| | | |
| — | — | — |
| A: ASSESSMENT AND DIAGNOSIS |
| | DIAGNOSIS | ICD-10 CODES |
| PRIORITIZE DIAGNOSIS | 1. | |
| | 2. | |
| | 3. | |
| | | | |
| — | — | — | — |
| VISIT CODES | | CPT BILLING CODES | |
| DIAGNOSTICS | | POC TESTING | |
| | | TESTS REVIEWED | |
| | | |
| — | — | — |
| P: PLAN |
| ACTIONS | 1. | Diagnosis: <br>Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)<br>Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)<br>Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.<br>Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning. |
| | 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) | | Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver. |
| FOLLOW UP | | |
**## NU611WeeklySOAPnoteinstructionsWeeks234-rev32023.docx**
Over the course of the semester you will choose 1 patient encounter each week to document an extended SOAP note for. In Weeks 2, 3, and 4, you will submit only the subjective and objective data sets for your chosen encounter.
It is expected that you vary the primary focus of each note to ensure you are receiving quality feedback for several types of patient encounters to include acute, chronic and wellness encounters. You are not to utilize the same type of encounter, acute/chronic health condition or wellness exam, more than once unless you have received approval to do so from your clinical faculty person.
Each SOAP note carries a 30-point value.
SOAP notes will be evaluated using a standardized rubric. Please review the evaluation criterion to ensure that your SOAP notes are constructed to address the required elements and desired level of achievement.
For planned weekly clinical experiences submission of the SOAP notes would be accomplished by submitting one SOAP note weekly for weeks 2 through week 7.
For planned and approved condensed, compressed or alternate clinical experiences, submission of the SOAP note would be dependent on the approved clinical schedule. This may mean that more than 1 SOAP note would need to be submitted on a weekly basis. If you are not in clinical for weeks where a SOAP note is due a ‘0’ will be input into the Grade Center as a place holder until you have submitted the required assignment.
**## SOAPNoteTemplate-Final.docx**
| | |
| — | — |
| **SOAP Note _______**<br>NU___:_________<br>Herzing University | **Name:_________________________**<br>Typhon Encounter #: _____________________<br>**Comprehensive:____Focused:____** |
| | | |
| — | — | — |
| S: SUBJECTIVE DATA |
| CC: | What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased. |
| HPI: | Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary] |
| PMH: | This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. |
| ALLERGIES | State the offending medication/food and the reactions. |
| MEDICATIONS | Names, dosages, and routes of administration along with indication of use. |
| SH | Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. |
| FH | Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known. |
| HEALTH PROMOTION & MAINTENANCE | **Required for all SOAP notes:** Immunizations, exercise, diet, etc. Remember to use the <br>[United States Clinical Preventative Services Task Force (USPSTF)](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams. |
| ROS <br>(put N/A in sections not completed day of exam) | Constitutional | |
| | Head | |
| | Eyes | |
| | Ears, Nose, Mouth, Throat | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |
| | | | | |
| — | — | — | — | — |
| O: OBJECTIVE DATA |
| VITALS: | HR: | RR: | BP: | Temp: |
| | SpO2%: | Ht: | Wt: | BMI: |
| | Age: | LMP: | PAIN: | |
| 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 | |
| | Head | |
| | Eyes | |
| | ENT, Mouth | |
| | Neck | |
| | Cardiovascular/Peripheral Vascular | |
| | Respiratory | |
| | Breast | |
| | Gastrointestinal | |
| | Genitourinary Male |
| | · External Exam | |
| | · Internal Exam | |
| | Genitourinary Female |
| | · External Exam | |
| | · Internal Exam | |
| | Musculoskeletal | |
| | Integumentary | |
| | Neurological | |
| | Psychiatric | |
| | Endocrine | |
| | Hematologic/Lymphatic | |
| | Allergic/Immunologic | |
| | Other | |
| | | |
| — | — | — |
| A: ASSESSMENT AND DIAGNOSIS |
| | DIAGNOSIS | ICD-10 CODES |
| PRIORITIZE DIAGNOSIS | 1. | |
| | 2. | |
| | 3. | |
| | | | |
| — | — | — | — |
| VISIT CODES | | CPT BILLING CODES | |
| DIAGNOSTICS | | POC TESTING | |
| | | TESTS REVIEWED | |
| | | |
| — | — | — |
| P: PLAN |
| ACTIONS | 1. | Diagnosis: <br>Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)<br>Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)<br>Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.<br>Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning. |
| | 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) | | Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver. |
| FOLLOW UP | | |
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