UOPX Material - University of Phoenix
University of Phoenix MaterialSOAP Note TemplateDate and identifying datacc: Subjective: OLDCARTS, pertinent ROS, FH, SH, medical and surgical history, meds, allergies, and LMPObjective: Vital signs including BMI. Only pertinent systems such as general, HEENT, neck, abdomen, lymph, GU, pelvic, breast, rectal, neuro, psych, pulm, and cardiac should be included on all SOAP notes.Labs: Only pertinent labs or other diagnostic informationAssessment: Diagnoses—including ICD-10 and qualifying statement such as stable or needs tighter control. Include health maintenance.CPT visit code – Office visit/how comprehensive and the CPT code includedSeparated and in a grid format: Differential diagnoses and how they were ruled out.Plan: Plan should be in grid format with the plan on the left and the rationale and EBP/supporting documentation on the right.Include the following:Complete prescription information: drug, dose, directions, quantity, refillsInstructions to continue, discontinue, or start medicationsDiagnostic tests in the proper order and reason for the order—for example, CT abdomen and pelvis with and without contract, Dx, LLQ abdominal painLabs including appropriate serum panels—for example, BMP, CBC with diff. TSH, T4 UA C&SPatient education pertinent to health conditionFollow-upReferralsPlanRationale and EBP/Supporting DocumentationStart lisinopril 10 mg 1 PO QD #30 0 refillsJNC 7: All diabetics should be on ACE inhibitor(NHLBI 2004).Continue ASA 81 mg dailyAHA recommends aspirin therapy in all patients over the age of 40 years with smoking history (AHA, 2007).Start metformin 500 mg 1 PO BID #60 3 refillsADA recommends the biguanide metformin for initial drug therapy in diabetics who do not have contraindications (ADA, 2008).Chest X-ray PA and lateralAHA and ADA recommend screening CXR to evaluate for cardiopathy (AHA, 2007; ADA, 2008) ................
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