UOPX Material - University of Phoenix



University of Phoenix Material

Episodic SOAP Note Template

Date and identifying data

cc:

Subjective: OLDCARTS, pertinent ROS, FH, SH, medical and surgical history, meds, allergies, and LMP

Objective: 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 information

Assessment: Diagnoses—including ICD-9 and qualifying statement such as stable or needs tighter control. Include health maintenance.

CPT visit code – Office visit/how comprehensive and the CPT code included

Separated 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, refills

• Instructions to continue, discontinue, or start medications

• Diagnostic tests in the proper order and reason for the order—for example, CT abdomen and pelvis with and without contract, Dx, LLQ abdominal pain

• Labs including appropriate serum panels—for example, BMP, CBC with diff. TSH, T4 UA C&S

• Patient education pertinent to health condition

• Follow-up

• Referrals

|Plan |Rationale and EBP/Supporting Documentation |

|Start lisinopril 10 mg 1 PO QD #30 0 refills |JNC 7: All diabetics should be on ACE inhibitor |

| |(NHLBI, 2004). |

|Continue ASA 81 mg daily |AHA 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 refills |ADA recommends the biguinide metformin for initial drug therapy in |

| |diabetics who do not have contraindications (ADA, 2008). |

|Chest X-ray PA and lateral |AHA and recommend screening CXR to evaluate for cardiopathy (AHA, |

| |2007). |

References

American Diabetes Association. (2008). Can meformin prevent or delay type 2 diabetes? Retrieved from

American Heart Association. (2007). Cardiomyopathy. Retrieved from

American Heart Association. (2007). Cardiovascular disease death rates decline, but risk factors still exact heavy toll. Retrieved from

National Heart Lung and Blood Institute. (2004). The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure (JNC 7). Retrieved from

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