soap note format

 



SOAP Note Form



S/ Identifying Information:   (initials, age/DOB, gender, reliability)
Family Hx: 

 








Personal/Social Hx:



Chief Complaint/RFE:








Hx Present Illness: (7 Variables but do not list as such)






CURRENT HEALTH



Medications:



Allergies:



Last PE & Screenings:



Immunization Status:



LMP & Birth Control (if applicable)



PMH



Illnesses & Trauma:



Hospitalizations/Surgeries:



OB Hx/Sexual Hx:



Emotional/Psy Hx:



REVIEW OF SYSTEMS



General



Nutrition



Skin/Hair/Nails



HEENT



Breasts



Respiratory



CV/peripheral vascular 

 



GI



GU



MSK



Psych



Neuro



Lymph/Heme/Endocrine



O/ Physical Exam: T:        P:        R:        BP:          HT:         WT:         BMI:



General



Skin



Head



EENT



Neck 



Breasts/Chest



Lungs



Heart/ perip vascular



Abdomen



Genitalia/Rectum



Lymph



MSK



Neuro



Medical Dx: (2max)
Rule Outs (only if applicable):



Health Profile:



age/gender/racial  risks:



Pertinent Positives:(1DX)


personal/family:



screening needs:



Pertinent Negatives:
counseling needs:



Immunization/chemo needs:



Differential DX:(3-5) 
Alteration in Health Prevention R/T:



Screening deficits:



Counseling deficits:



Nursing Dx: 
Immunization/chemo deficits:










 



I. PLAN:  Do separate sections in the plan  to include: Max 1-2 pages 

 

Diagnostics:

 

Medications/Treatments:

 

Education:

 

Follow-up:

 

Referrals:

 

Prevention Plan:

 


II. Rationale: ( Max 2 pages)


III. Patho: (Max 2 pages)



 

 

 

 

 

 

 

Mixed Up Soap Note

Name

Institution

 

 

 	
What type of history will you obtain for this visit?


 	
Presenting complain
 	
History of presenting complaint
 	
Past medical history (Sataloff, 2019)
 	
Drug history
 	
Family history
 	
Social history


 	
What additional history would you obtain from the family that is significant to A.J.’s situation


 	
Family history e.g. Cardiac and diabetes history
 	
Presence of genetic conditions in the family


 	
Practice using clinical reasoning and list possible diagnoses for A.J. based on the subjective information provided


 	
Muscle or tendon injury
 	
Medial tibial stress syndrome
 	
Stress fracture,
 	
Exertional compartment syndrome
 	
Nerve entrapment


 	
For each of the following:
 	
Medical Diagnosis: Muscle or tendon injury:
 	
Pathophysiology


 	
Muscle strain occurs from overstretched muscles and is common among sporting people. Symptoms include leg pain and mobility difficulties among others.
 	
Muscle strains cause excessive fiber stretching due to exertion of tensile force at the muscle. The pathophysiological process is characterized by destruction, repair and remodeling. Destruction involves tearing and myofibrils necrosis, creation of hematoma and division of inflammatory cells (Bengtsson, Ekstrand, Waldén & Hägglund, 2017). Repair and remodeling phases involve necrotic tissue phagocytosis, myofibrils regeneration and concomitant development of connective scar tissue, neoformation of vessels and growth of neurons also occur (Hamilton et al., 2020) MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment


 	
ICD 10 code: ICD-10-CM Code S86
 	
Diagnosis 2: Medial tibial stress syndrome


 	
Pathophysiology:
 	
Clinical exercise induced pain caused by repetitive loading stress during running and jumping and triggered on palpation over a length of ≥5consecutive centimeters. It occurs along the posteromedial tibial border.
 	
Foot inversion by dorsiflexes of the tibialis anterior is followed by extension of the great toe. Other toes extend causing pain and dysfuctions.
 	
ICD-10-CM Diagnosis Code S83.132A
 	
Differential diagnosis, 3-5 Differentials
 	
Stress fracture

 	
Tiny cracks in bones caused by repetitive force, often from overuse — such as repeatedly jumping up and down or running long distances. Stress fractures can also develop from normal use of a bone that’s weakened by a condition such as osteoporosis.
 	
ICD-10-CM Diagnosis Code M84.35



 

 	
Exertional compartment syndrome
 	
It is associated with pain and pressure on the leg due to failure of muscle expansion on the affected tissues. It causes inflammation, pain and disability of arms and legs. It is nerve condition or exercise induced.
 	
ICD-10-CM Diagnosis Code M79.A22 (ICD10data, 2018).
 	
Nerve entrapment
 	
It is characterized by pain, tingling, numbness and muscle weakness. It is a medical condition resulting from direct exertion of pressure on the nerves (Black, Brindle & Honaker, 2016). Localized structural changes and microvascular function interferences cause dysfunction of peripheral-nerves (Kastenschmidt, Mannaa, Muñoz & Villalta, 2019).
 	
ICD-10-CM Diagnosis Code S84.02XD

 

 	
Pertinent positives

 	
muscle injury;
 	
pain


 	
Pertinent negatives

 	
Broken bone



 

 

References

 

Kastenschmidt, J. M., Mannaa, A. H., Muñoz, K. J., & Villalta, S. A. (2019). Immune System Regulation of Muscle Injury and Disease. In Muscle Gene Therapy (pp. 121-139). Springer, Cham.

Hamilton, B., Pollock, N., Reurink, G., de Vos, R. J., Purdam, C., & Thorborg, K. (2020). Muscle Injury Classification and Grading Systems. In Prevention and Rehabilitation of Hamstring Injuries (pp. 189-198). Springer, Cham.

Bengtsson, H., Ekstrand, J., Waldén, M., & Hägglund, M. (2017). No difference in muscle injury rates during professional football matches preceded by three to five days of recovery. British Journal of Sports Medicine, 51(4), 294-294.

Black, J. M., Brindle, C. T., & Honaker, J. S. (2016). Differential diagnosis of suspected deep tissue injury. International wound journal, 13(4), 531-539.

ICD10data. (2018). The Web’s Free 2019/2020 ICD-10-CM/PCS Medical Coding Reference. Retrieved from https://www.icd10data.com/

Sataloff, R. T. (2019). Patient history. Obesity and Voice, 65. MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment