Tension-type headache :Focused SOAP Note

Focused SOAP Note Instructions

Must use the sample templates for your soap note

Grading Rubric

Student______________________________________
This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).
b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).
c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).
b) Pertinent positives and negatives must be documented for each relevant system.
c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4) Assessment (___10pts.): Encounter paragraph and diagnoses should be clearly listed and worded appropriately including ICD10 codes.

5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

6) Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

Comments:

Total Score: ____________ Instructor: __________________________________

 

Guidelines for Focused SOAP Notes

• Label each section of the SOAP note (each body part and system).
• Do not use unnecessary words or complete sentences.
•  Use Standard Abbreviations

S: SUBJECTIVE DATA (information the patient/caregiver tells you).

Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis, and physician-recommended return(s) for this patient visit. The patient’s own words should be in quotes.

History of present illness (HPI): a chronological description of the development of the patient\’s chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last patient encounter.

Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-appropriate immunization status.

Family History (FH): Update significant medical information about the patient\’s family (parents, siblings, and children). Include specific diseases related to problems identified in CC, HPI or ROS.

Social History(SH): An age-appropriate review of significant activities that may include information such as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, the extent of education, and sexual history.

Review of Systems (ROS). There are 14 systems for review. List positive findings and pertinent negatives in systems directly related to the systems identified in the CC and symptoms which have occurred since the last visit;

(1) constitutional symptoms (e.g., fever, weight loss)

(2) eyes

(3) ears, nose, mouth and throat

(4) cardiovascular

(5) respiratory

(6) gastrointestinal

(7) genitourinary

(8) musculoskeletal

(9) integument (skin and/or breast)

(10) neurological

(11) psychiatric

(12) endocrine

(13) hematological/lymphatic

(14) allergic/immunologic.

The ROS should mirror the PE findings section.

0: OBJECTIVE DATA (information you observe, assessment findings, lab results).

A sufficient physical exam should be performed to evaluate areas suggested by the history and patient\’s progress since last visit. Document specific abnormal and relevant negative findings. Abnormal or unexpected findings should be described. You should include only the information which was provided in the case study, do not include additional data.

Record observations for the following systems if applicable to this patient encounter (there are 12 possible systems for examination): Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lymphatic/immunologic/lab testing. The focused PE should only include systems for which you have been given data.

NOTE: Cardiovascular and Respiratory systems should be assessed on every patient regardless of the chief complaint.

Testing Results: Results of any diagnostic or lab testing ordered during that patient visit.

A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code)

List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.
Remember: Your subjective and objective data should support your diagnoses and your therapeutic plan.
Do not write that a diagnosis is to be \”ruled out\” rather state the working definitions of each differential or primary diagnosis (es).
For each diagnoses provide a cited rationale for choosing this diagnosis. This rationale includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the focused PE findings and tests results that support the dx. Include the interpretation of all lab data given in the case study and explain how those results support your chosen diagnosis.

P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include an EBP citation.

1. Medications prescribe dispensing information and provide EBP to support ordering each medication. Be sure to include both prescription and OTC medications.
2. Additional diagnostic tests include EBP citations to support ordering additional tests
3. Education this is part of the chart and should be brief, this is not a patient education sheet and needs to have a reference.
4. Referrals include citations to support a referral
5. Follow up. Patient follow-up should be specified with the time or circumstances of return. You must provide a reference for your decision on when to follow up.

Solution

 

Focused SOAP Note

Student’s Name

Institutional Affiliations

 

Focused SOAP Note

 

Patient Information:

 

Patient Initials: H.K.                 Age: 24 years               Gender: Female           Race: Hispanic

 

S: SUBJECTIVE DATA

 

Chief Complaint (CC): “I have a sore throat.”

History of present illness (HPI): H.K. is a 24-year-old Hispanic female patient who has visited the clinic for a wellness checkup. She reports having a recurrent headache. These symptoms have lasted for the last 24 hours. Her last wellness checkup was five years ago.

Onset: Acute symptoms.

Location: Head.

Duration: 24 hours.

Characteristics: Dull headache.

Aggravating Factors: Deep thought.

Relieving Factors: Relaxed mind.

Treatment: No treatment.

Severity: 5/10.

Past Medical History (PMH): Denies a history of medical condition.

Current medications: None.

Allergies: None.

Immunization status: Up to date.

Family History (FH): Father died at the age of 72 years from stroke complications. Mother is alive and has hypertension.

Social History (SH): H.K. is a university student. She currently lives with her mother. She neither drinks alcohol nor consumes cigarettes.

 

Review of Systems (ROS).

 

Constitutional symptoms: Denies fever, denies weight loss.

HEENT: Reports a headache. Denies eye problems. Denies issues with vision. No nasal problems reported. Denies mouth ulcers. Does not report difficulty swallowing.

Cardiovascular: Denies tightness of the chest.

Respiratory: Does not report difficulty breathing.

Gastrointestinal: Denies stomachache. Denies constipation and vomiting.

Genitourinary: Does not report any issues with the genitals. Denies a burning sensation during urination.

Musculoskeletal: H.K. denies general body weakness, denies pain in the joints.

Integument (skin and/or breast): Does not report rashes in the skin. Denies pain in both breasts.

Neurological: Reports a recurrent headache. Denies body weakness.

Psychiatric: Denies stress.

Endocrine: Denies abnormal changes in urination frequency. Denies abnormal sweating.

Hematological/lymphatic: Denies blood-related disorders such as sickle-cell anemia and hemophilia.

Allergic/immunologic: H. K. is not allergic to any foods or drugs.

 

OBJECTIVE DATA

 

Vital signs: Height; 42 inches, heart rate; 92, respiratory rate; 20, weight=54.8 lb.

General: H.K. appears healthy. She is attentive and neatly dressed.

HEENT: Head is normocephalic without evidence of physical injury. The sclera is white. Both ears are symmetrically positioned on both sides of the head. No evidence of blockage in the ears. Nasal mucosa is white and pink, without lesions. No lesions in the mouth. The throat is non-erythematous.

Cardiovascular: No gallop. No murmur.

Respiratory: No wheezing.

Musculoskeletal: No joint pain on palpation. The patient’s gait is normal.

Neurological: The severity of headache is 6/10 on a pain scale.

Psychiatric: No anxiety, no depression.

Testing Results: No tests ordered.

 

A: ASSESSMENT:

 

Differential diagnoses:

• Tension-type headache
• Psychiatric disorder
• Idiopathic intracranial hypertension

Primary Diagnosis: Tension-type headache

2021 ICD-10-CM Diagnosis Code G44. 209: Tension-type headache, unspecified, not intractable

P: PLAN

1. Medication:

• Two 200 mg of ibuprofen 3 times a day prescribed. The use of ibuprofen for the treatment of tension-type headache is supported by evidence-based guidelines (Yancey & Saas, 2016).

2. Additional diagnostic tests:

• The Diagnostic and Statistical Manual of mental disorders version 5 (DSM-5) was administered to assess the presence of any mental illnesses such as depression and anxiety (Maurer et al., 2018).

3. Education:

• K. was educated to avoid stress and adhere to the prescribed medication (Edelman et al., 2017).

4. Referrals:

• K. was referred to a neurologist for a detailed assessment (García-Azorín et al., 2020).

5. Follow up:

• K. was advised to call the clinic incase disease symptoms worsen.
• She was informed to visit the clinic in two weeks for monitoring and follow-up.

References

Edelman, C., Mandle, C., & Kudzma, E. (2017). Health promotion throughout the life span. 9^th ed. Elsevier Health Sciences. ISBN: 0323416748, 9780323416740

García-Azorín, D., Farid-Zahran, M., Gutiérrez-Sánchez, M. González-García, M. N., Guerrero, A., & Porta-Etessam, J. (2020). Tension-type headache in the emergency department diagnosis and misdiagnosis: The TEDDi study. Scientific Reports, 10, 2446. https://doi.org/10.1038/s41598-020-59171-4.

Maurer, D., Raymond, T. & Davis, V. (2018). Depression: Screening and diagnosis. American Family Physician, 98(8):508-515. https://www.aafp.org/afp/2018/1015/p508.html

Yancey, J. & Saas, P. (2016). Ibuprofen for treatment of episodic tension-type headaches. American Family Physician, 93(9), https://www.aafp.org/afp/2016/0501/od1.html