NGR6002c Advance Health Assessment

Directions: Read over the SOAP note and formulate a primary diagnosis.  Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.Case Study: 

A 47-year-old African-American man presents to your office for a follow-up visit. He was seen 3 weeks ago for an upper respiratory infection and noted incidentally to have a blood pressure of 164/98 mm Hg. He vaguely remembered being told in the past that his blood pressure was “borderline.” He feels fine, has no complaints, and his review of systems is entirely negative. He does not smoke cigarettes, drinks “a couple of beers on the weekends,” and does not exercise regularly. He has a sedentary job. His father died of a stroke at the age of 69. His mother is alive and in good health at the age of 72. He has two siblings and is not aware of any chronic medical issues that they have. In the office today, his blood pressure is 156/96 mm Hg in his left arm and 152/98 mm Hg in the right arm. He is afebrile, his pulse is 78 beats/min, respiratory rate 14 breaths/min, he is 70-in tall, and weighs 210 lb. A general physical examination is normal.

SOAP NOTE GRADING RUBRIC

Guidelines:

1-Use the case study in the description to complete the assignment. Fill in the missing details for each

required section that would be expected for the diagnosis.

SUBJECTIVE Analysis (0.2 POINT)

Score received

1-Subjective section should include:

a-Chief complaint (CC)

b-History of present illness (HPI)- All 7

attributes (location, quality, quantity or severity,

timing including onset, frequency, and duration,

setting in which it occurs, aggravating or

relieving factors, and associated symptoms)

c-Past history (Medical, Surgical,

Obstetric/Gynecology, Psychiatric)

d-family history (3 generation pedigree of first-

degree relatives, i.e. parents, siblings, children)

e. Personal and social history (i.e. sexual history

5p’s)

f. Review of systems (ROS, pertinent positives

and/or negatives)

g. Developmentally appropriate-i.e.

developmental history if peds, functional

assessment and/or dementia screen if elderly

a-Identified and collected the necessary data

b-Categorized and organized data using the

appropriate format

c-Incorporated all pertinent data/facts

d- Used proper documentation and proper billing

code

e- PATIENT’S CULTURE MUST BE NOTED

OBJECTIVE (0.2POINT)

Score received

1-Objective section should include:

a. General survey

b. Vital Signs (including BMI and growth

chart if applicable)

c. All other necessary body systems

d. Diagnostic test if available

a. Identified and collected the necessary data

b. Categorized and organized data using the

appropriate format

c.Incorporated all pertinent data/facts
d. Used proper documentation and billing

code

SUBJECTIVE Analysis (0.2 POINT)

Score received

ASSESSMENT (0.2 POINT)

Score received

1- Identified correct diagnosis, ICD-10 code, and

correct differential diagnosis

a-Filtered relevant data from irrelevant data

b.-Interpreted relationships/patterns among data

(e.g., noted trends)

c.Integrated information to arrive at diagnosis

d.Identified risk factors

d. Used proper documentation

PLAN Analysis (0.2POINT)

Score received

a-Recommended an appropriate plan for each

problem

b-Included recommendations for non-drug and

drug therapy

c-Included recommendations for monitoring

d- Included health education

e- Included followup & referrals

f- include cultural considerations of patient care

Incorporate the patient’s culture on the

demographic section on SOAP notes.

FORMAT (0.2 POINT) Score received

1- APA

2- References Current (atleast two references,

one of which needs to be uptodate and the other

a clinical practice guideline from a peer

reviewed journal article or national organization

such as AAFP, ACOG, USPSTF)

3- Writing clear, concise

4- Summary/Conclusion

TOTAL: /1

SOAP FORMAT & RUBRIC

Initials of Patient:

Patient Age:

Patient Ethnicity:

Initials of Provider:

Clinical Setting:

Patient Status: ____New ____Established

SUBJECTIVE DATA; GRADE RECEIVED: _____

Overall Instructions:
1. Identified and collected the necessary data

2. Categorized and organized data using the appropriate format

3. Incorporated all pertinent data/facts

4. Used proper documentation

5. LIST at the end of your subjective section the billing level : Problem Focused,

Expanded problem focused, detailed, comprehensive (use guidelines for new vs.

established patient

6. Identify cultural influences on care

FORMAT
Chief Complaint:

History of Present Illness:

Location

Quality

Quantity or Severity

Timing (Onset, Duration, Frequency)

Setting

Aggravating and relieving Factors

Associated Symptoms

Past history (include dates):

PMH

• Chronic illness (date of onset) & hospitalizations (dates)

Medications: Dose, route, frequency

• Allergies: Medications, Foods, Other Allergens

PSH

• (Dates, indications, and types of operations)

Past Psychiatric Hx

• (Illness and timeframe, diagnosis, hospitalizations and

treatments)

Obstetrical/Gynecological (obstetric history & menstrual history)

Obstetrical History

• (Gravida-Para-TPAL)

Menstrual History

• (Menarche, LMP, PMP, regular/irregular,

frequency, duration, quality of flow, Menopause,

Post-menopausal bleeding, HRT)

Health Promotion/Maintenance: Colonoscopy, Prostate (PSA), BP

check, Cholesterol, Annual Physical, Mammography, PAP, Eye

Exam, Dental etc., Immunizations

Functional Status: ADLs and IADLs

Family History: Alive, Deceased, Age, Diseases, Health Conditions that place patient at risk

(ages)

Parents

Siblings

Children

Social History:

Cultural Background

Spiritual History/Religious Affiliation and Practices

Complementary/Alternative Care Practices:

Type of Family (Nuclear, Extended etc.)

Marital Status

Parental Status

Work History

Financial History

Diet

Exercise (Frequency, intensity, Time, Type)

Stress Management

Sleep

Social Support

Sexual history (5ps)

Use of alcohol, smoking, or recreational drugs

Living Arrangements

Travel History

Review of Systems:

Constitutional:

Head/face:

Eyes:

Ears:

Nose:

Mouth/Throat/ Neck:

Respiratory:

Cardiac:

Breast:

GI:

GU:

GYN (female):

Reproductive (Male):

Musculoskeletal:

Skin/Integument:

Psychiatric:

Neuro:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

Determine Which LEVEL of HISTORY (Choose one):

Focused HPI (1-3 findings); ROS N.A; PFSH N.A

Expanded HPI (1-3 Findings); ROS 1 or more; PFSH N.A.

Detailed HPI (4 or more findings); ROS 2-9 systems; PFSH one

Comprehensive HPI (4 or more findings or status of 3 or more chronic stable

conditions; ROS 10-14; PFSH 2-3 areas

OBJECTIVE DATA; Grade received_____

Overall Instructions:
1. Identified and collected the necessary data

2. Categorized and organized data using the appropriate format

3. Incorporated all pertinent data/facts

4. Used proper documentation

5. LIST at the end of your subjective section the billing level : Problem Focused,

Expanded problem focused, detailed, comprehensive (use guidelines for new vs.

established patient

FORMAT:

Vital Signs:

Oxygen Saturation:

Ht:

Wt:

BMI:

Constitutional:

General:

Physical Examination:

Head/face:

Eyes:

Ears:

Nose:

Mouth/Throat/ Neck:

Respiratory:

Cardiac:

Breast:

GI:

GU:

GYN (female):

Reproductive (Male):

Musculoskeletal:

Skin/Integument:

Psychiatric:

Neuro:

Hematologic/Lymphatic/Immunologic:

Determine Billing LEVEL OF PHYSICAL OBJECTIVE EXAM (choose one):

Focused: 1 body area or organ system (1-5 elements);

Expanded problem focused (2-4 body are or organ system (6-11 elements);

Detailed (5-7 see notes);

Comprehensive (8 organ systems see notes);

Laboratory Data Already Ordered and Available for Review (If not done will go

in plan):

Diagnostic Procedures/Data Already Ordered and Available for Review (If not done will go

in plan):

ASSESSMENT; GRADE RECEIVED____
1) Main Diagnosis/Problem:

2) Additional Health Problem/Dx:

3) Differential Diagnoses for top diagnoses

4) Identify Risk Factors

PLAN; GRADE RECEIVED________

For Each Diagnosis or Health Problem Identified as Appropriate:

Additional Laboratory Tests or Diagnostic Data Needed

Pharmacologic Management:

Drug, dose, route, frequency, Disp amount

SIG (write like a prescription)

Non-Pharmacologic Management: i.e. hot packs, ice, position changes, TENS unit

etc.

Complementary Therapies:

Health Education:

Referrals:

Follow-up Appointment:

For the Encounter Final Level of Decision Making: (give rationale for level which is based

on Hx, physical, Decision making); Choose one

Straightforward:

Low Complexity:

Moderate Complexity:

High Complexity:

Billing Level: Give the reason for the Billing by E and Coding as per Number of Systems

Reviewed and Level of Physical Exam.

Patient Status: New or established

Level of history

Level of physical (exam)

Level of Medical decision making

• 1-Use the case study in the description to complete the assignment. Fill in the missing details for each required section that would be expected for the diagnosis.