Case Study 2: HPI: Ms. Juggenmeir is a 71–year old Female who comes into your office with concerns of fatigue and dry skin. She is a retired Banker. She is AAOx4, ambulatory, and lives by herself. She does report increased fatigue no matter how much sleep she gets. She is also concerned that she may need to come off of one of her meds because her hair is thinning. She had labs done and also was informed they would review results at this visit. Other pertinent diagnoses include Hypertension, Hyperlipidemia, and Vitamin D deficiency. She admits to not taking her vitamin d daily as prescribed. RESOURCE FOR THIS WEEK: Review Endocrine-related Evidence Based Practice Guidelines. Ms. Juggenmeir is a 71 y/o female who is AAOX4. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She denies any falls or pain. (All other Review of System and Physical Exam findings are negative othe
MJ, a 71-year-old, female, White origin
S
CC: “Fatigue and dry skin.”
HPI: MJ is a 71-year-old female of white origin who came to the office with concerns about dry skin and fatigue. She says that she has been feeling fatigued regardless of the amount of sleep she gets for the last five days. She also complains of thinning because of her meds. Associated symptoms include weight gain, constipation, increased sensitivity to cold, hoarseness, muscle weakness, muscle and joint aches, and a puffy face. She has not taken any medication to relieve the symptoms. She denies pain or falls.
Current Medications: Women’s One Day-Multivitamin daily, Fish Oil 1 tablet daily, Chlorthalidone 25mg daily, Amlodipine 5mg p.o. daily, Atorvastatin 40mg p.o. at bedtime daily, Losartan 100mg p.o. daily, Ergocalciferol 50,000 units PO once a month, and Aspirin 81mg p.o. daily
Allergies: I.V. Contrast, ACE Inhibitors
PMHx: She received the pneumonia vaccine three years ago. She does not remember information about the tetanus vaccine. Past medical illnesses include Vitamin D deficiency, Hyperlipidemia, and Hypertension.
Soc and Substance Hx: She is a retired Banker. She loves reading…
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Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S (subjective)
CC (chief complaint): a BRIEF statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” NOT “bad headache for 3 days”).
HPI (history of present illness): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
- Location: Head
- Onset: 3 days ago
- Character: Pounding, pressure around the eyes and temples
- Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia
- Timing: After being on the computer all day at work
- Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely better
- Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for use; also include over the counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately, including a description of what the allergy is (i.e., angioedema, anaphylaxis, etc.). This will help determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.
Soc and Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promo question here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx
Case Study 2: HPI: Ms. Juggenmeir is a 71–year old Female who comes into your office with concerns of fatigue and dry skin. She is a retired Banker. She is AAOx4, ambulatory, and lives by herself. She does report increased fatigue no matter how much sleep she gets. She is also concerned that she may need to come off of one of her meds because her hair is thinning. She had labs done and also was informed they would review results at this visit. Other pertinent diagnoses include Hypertension, Hyperlipidemia, and Vitamin D deficiency. She admits to not taking her vitamin d daily as prescribed. RESOURCE FOR THIS WEEK: Review Endocrine-related Evidence Based Practice Guidelines. Ms. Juggenmeir is a 71 y/o female who is AAOX4. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She denies any falls or pain. (All other Review of System and Physical Exam findings are negative othe
Patient Information:
Initials, Age, Sex, Race
S (subjective)
CC (chief complaint): a BRIEF statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” NOT “bad headache for 3 days”).
HPI (history of present illness): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
- Location: Head
- Onset: 3 days ago
- Character: Pounding, pressure around the eyes and temples
- Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia
- Timing: After being on the computer all day at work
- Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely better
- Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for use; also include over the counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately, including a description of what the allergy is (i.e., angioedema, anaphylaxis, etc.). This will help determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.
Soc and Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promo question here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: Illnesses with possible genetic predisposition, contagious, or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns (anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual (current and historical).
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other, any sexual concerns).
ROS (review of symptoms): Cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows:
- General:
- Head:
- EENT (eyes, ears, nose, and throat):
- :
Note: You should list these in bullet format, and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT:
- Eyes: No visual loss, blurred vision, double vision or yellow sclerae.
- Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Last menstrual period (LMP), MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.