Assingments % - How to Document Medical Histories and Treatment Plans

Problem-Focused SOAP Note Format
Demographic Data
Age and gender (must be HIPAA compliant)
Subjective
Chief Complaint (CC): A short statement about why they are there
History of Present Illness (HPI): Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment
Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance
Family Hx: any history of CA, DM, HTN, MI, CVA?
Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
Objective
Vital Signs
Physical findings listed by body systems, not paragraph form- Highlight abnormal findings
Assessment (the diagnosis)
At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each
Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation
Plan
Dx Plan (lab, x-ray)
Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)
Pt. Education, including specific medication teaching points
Referral/Follow-up
Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due
Reference
Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.

Struggling with where to start this assignment? Follow this guide to tackle your assignment easily!

Step-by-Step Guide for Writing Your Paper

This guide will help you systematically approach the assignment based on the provided instructions. Follow each step carefully to structure your paper and ensure you meet all requirements.

Step 1: Demographic Data

Begin your paper with a section titled “Demographic Data.” Here, you’ll include:

Age: The patient’s age (e.g., 23-year-old female).
Gender: The patient’s gender (e.g., female).
Subjective: The Chief Complaint (CC), which is a brief, direct statement about the patient’s reason for seeking care (e.g., “Patient here for severe headache”).

Step 2: History of Present Illness (HPI)

Write the History of Present Illness in a detailed paragraph form. Use the OLDCART acronym to guide you through the information:

Onset: When did the symptoms start?
Location: Where is the problem located?
Duration: How long has the patient been experiencing this issue?
Characteristics: What are the qualities of the symptoms (e.g., sharp, dull, throbbing)?
Aggravating Factors: What makes the condition worse?
Relieving Factors: What eases the condition?
Treatment: What treatments, if any, has the patient tried?

Step 3: Past Medical History (PMH)

Detail the patient’s Past Medical History. This includes:

Medical or surgical problems the patient has experienced.
Any hospitalizations or ongoing treatments.
List of medications the patient is currently taking.
Allergies and their specifics (medications, environmental, etc.).
Immunization status and preventative health measures taken (e.g., vaccines, screenings).

Step 4: Family History

Outline the Family History by including any genetic conditions or serious illnesses:

History of Cancer (CA), Diabetes (DM), Hypertension (HTN), Myocardial Infarction (MI), or Cerebrovascular Accident (CVA) in the family. This section should help identify potential hereditary health risks.

Step 5: Social History

Provide the Social History of the patient, covering aspects such as:

Nutrition: The patient’s diet.
Exercise: Whether they engage in physical activity and its frequency.
Substance Use: Any use of tobacco, alcohol, or drugs.
Sexual History: Safe sex practices, history of STIs, etc.
Occupation and School: Their work or educational status.

Step 6: Review of Systems (ROS)

For the Review of Systems, provide a comprehensive list of the patient’s symptoms based on body systems. This should be presented as individual systems (e.g., cardiovascular, respiratory, gastrointestinal). Highlight any abnormal findings from these systems.

Step 7: Objective Data

Vital Signs: Include the patient’s current vital signs (e.g., blood pressure, heart rate, temperature).
Physical Findings: List the physical findings from the examination in a clear format by body system. Highlight any abnormal findings.

Step 8: Assessment

Differential Diagnoses: Present at least two differential diagnoses. Provide a rationale for each diagnosis, and list pertinent positives (supporting facts) and negatives (facts that do not support it).
Final Diagnosis: Provide your final diagnosis based on the information. Offer rationale and explain it, including pertinent positives and negatives that influenced your decision. Additionally, include a pathophysiological explanation of the diagnosis.

Step 9: Plan

The plan section will include:

Diagnostic Plan: Any tests, labs, or imaging needed to further diagnose the condition (e.g., blood tests, X-rays).
Treatment Plan: List any medications prescribed, including:
- Dosage: How much medication is prescribed.
- Frequency: How often the patient should take the medication.
- Duration: How long they need to take it.
- Refills: If applicable, mention how many refills are provided.
Patient Education: Include educational points for the patient about their diagnosis and treatment. Be specific about medication teaching (e.g., how to take the medication, potential side effects).
Referral/Follow-up: Provide details on any necessary referrals (e.g., to specialists) or follow-up appointments.
Health Maintenance: Outline any health screenings, vaccines, or checkups that are due in the future (e.g., eye exams, pap smears).

Step 10: References

Include a list of references to justify your care decisions. Compare the care provided to national standards of care and national guidelines. Make sure to cite sources appropriately in your references section.