Chart 158 Key on SOAP Note R3
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School
Southern New Hampshire University *
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Course
123
Subject
Medicine
Date
Apr 3, 2024
Type
Pages
4
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Scribing Services Chart Readiness –
Template for Practice SOAP Notes 1.
Chart #:
158 1.
Chief Complaint(s):
Medical cannabis certification for chronic back pain.
2.
History of Present Illness: (Use full sentences and correct grammar/spelling, as well as proper medical terminology and medical phrasing
.) The patient is a 60-year-old male smoker with a past medical history of chronic back pain and schizophrenia who presents on 03/18/2018 for medical cannabis certification. He was prescribed opioids in the past, but he prefers not to take them and now seeks alternative treatment for his severe chronic back pain. He is also currently in physical therapy for treatment of leg and hip pain after a fall. He denies any current use of cannabis, stating that the last time he used this was at age 17, and he remembers the effects of its use. He does not plan on using cannabis daily, only 1-2 times per week. The patient was last hospitalized for schizophrenia in approximately 2010, and he reports his condition is well-controlled with medication. He has informed his psychiatrist about his preference for medical cannabis use and states they are "comfortable" with it. He has also discussed his preference to use medical cannabis with his roommate and his family, who agree with his plan and will help monitor him for any potential signs of a recurrent psychotic episode. He is currently out of work. Patient reports that at his most recent eye examination, he was told he had the beginning stages of cataracts.
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Scribing Services 3.
Review of Systems: (Write your Review of Systems in the answer space below this sample Review of Systems. Include only what was addressed during the encounter.) Constitutional: Negative chills, fever, fatigue HENT: Negative sore throat, congestion, otalgia Eyes: Negative diplopia, eye pain/discharge/redness Respiratory: Negative cough, sputum production, dyspnea, wheezing, hemoptysis CV: Negative chest pain, dyspnea on exertion, orthopnea GI: Negative abdominal pain, dyspepsia, nausea/vomiting, diarrhea, constipation, hematochezia, melena GU: Negative pelvic pain, dysuria, hematuria, frequency, nocturia MS: Negative back pain, arthralgia, myalgia, limited range of motion Integumentary: Negative rash, erythema, pruritus, abrasion, laceration Neurological: Negative cephalgia, dizziness, paresthesia, dysphasia Psychological: Negative anxiety, depression, suicidal/homicidal ideation, insomnia Endocrine: Negative heat/cold intolerance, hair loss, significant weight gain/loss, polyuria, polydipsia Hematologic/Lymphatic: Negative easy bleeding, ecchymosis, lymphadenopathy
MS: Positive back, leg, and hip pain. 4.
Past Medical History: (If verbalized during the encounter.)
Schizophrenia, chronic back pain, cataracts. 5.
Past Surgical History: (If verbalized during the encounter.)
N/A 6.
Social History: (If verbalized during the encounter.)
No current use of cannabis, last used at age 17. 7.
Family History: (If verbalized during the encounter.)
N/A
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Scribing Services 8.
Diagnostic Data Discussed:
(All current diagnostic results reviewed during the encounter, including lab work, imaging, EKGs, etc.)
N/A 9.
Physical Examination: (Write your Physical Examination in the answer space below this sample Physical Exam. Include only what was addressed during the encounter.) Constitutional: Well-developed, well-nourished Head: Atraumatic, normocephalic Neck: Supple, full range of motion, no masses, no bruit, no jugular vein distention Eyes: Pupils equal, round, reactive to light; extraocular movements intact; sclerae anicteric; normal visual fields ENT: Tympanic membranes clear; nasal mucosa moist; oropharynx clear, no oral lesions, healthy dentition Cardiovascular: Regular rate and rhythm, no murmur or gallop, normal S1 and S2; distal pulses intact Respiratory: Clear to auscultation bilaterally, normal aeration Abdomen: Soft, nontender, nondistended; normoactive bowel sounds; no organomegaly Breasts: Bilateral breasts without mass, fullness, or tenderness Back: No tenderness, normal curvature Extremities: No edema, no muscular or joint tenderness Lymphatic: No palpable nodes, no adenopathy Skin: No suspicious lesions identified Neurological: Speech clear, memory intact, CN II-XII intact, normal gait, 5/5 strength bilaterally, equal sensation bilaterally Psychiatric: Appropriate, normal judgement
(*Not verbalized provider
—
ask about a normal template.) 10.
Assessment and Plan: (Different formats may be used, such as bulleted style as shown in this example.)
1) Breast cancer •
Start Arimidex 1 mg daily. •
Symptoms reviewed/discussed. •
Ordered: CBC, CMP, CA 15-3, CEA
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Scribing Services •
Follow up in 3 months. 2) Hypertension •
Continue metoprolol 25mg BID. •
Encouraged to monitor blood pressure at home three times daily. •
Bring list of blood pressure readings to next appointment.
Assessment: 1. Severe chronic intractable pain. 2. History of schizophrenia. Plan: 1.
Medical marijuana certification was given to the patient today. Informed consent, short-
term and long-term risks, side effects, benefits, and alternatives were discussed with the patient. I spent 15 minutes counseling the patient. We will see him back in July 2018 for a physical with blood work done the week before. Order for blood work to be obtained at Quest was given to the patient. 2.
The patient has discussed cannabis use with his psychiatrist, roommate, and family, who all agree with its use and will monitor him for any signs of a psychotic episode. 11.
Orders: (All provider orders that should be pended for this visit, including medications, referrals, and lab work and other diagnostic studies.) Blood work (unspecified). Billing Code: 99213 12.
Scribe Attestation:
(Fill in the blanks in the following statement.) Scribed for Dr. _____ by _____, medical scribe, on _____ at _____. I, Dr. _____, have personally reviewed and agree with the information entered by the scribe. Scribed for Dr. _____ by Sophia Petrillo, medical scribe, on 03/18/2018 at 10:57 AM EST. I, Dr. _____, have personally reviewed and agree with the information entered by the scribe.