who can do a SOAP NOTE for me, catered to a 13 yr old kid following the attach template THISIS NEEDED BY 1145PM

SOAP NOTE TEMPLATE

Review the Rubric for more Guidance

Demographics

Begins with patient initials, age, race, ethnicity and gender (5 demographics)

Chief Complaint (Reason for seeking health care)

Includes a direct quote from patient about presenting problem

History of Present Illness (HPI)

Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)

Allergies

Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)

Review of Systems (ROS)

Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to chief complaint AND uses the words “admits” and “denies”

General:

HEENT:

Neck:

Lungs:

Cardio

Breast:

GI:

M/F genital:

GU:

Neuro

Musculo:

Activity:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

Vital Signs

Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)

Labs

Includes a list of the labs reviewed at the visit, values of lab results and highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed

Medications

Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)

Past Medical History

Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current

Past Surgical History

Includes, for each surgical procedure, the year of procedure and the indication for the procedure

Family History

Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.

Social History

Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.

Health Maintenance/ Screenings

Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests

Physical Examination

Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint

General:

HEENT:

Neck:

Lungs:

Cardio

Breast:

GI:

M/F genital:

GU:

Neuro

Musculo:

Activity:

Psychosocial:

Derm:

Diagnosis

Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)

Differential Diagnosis

Includes at least 3 differential diagnoses for the principal diagnosis

ICD 10 Coding

Correctly includes all ICD-10 codes relevant to the diagnoses addressed at the visit

Pharmacologic treatment plan

Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above

Diagnostic/Lab Testing

Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time

Education

Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives002E

Anticipatory Guidance

Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))

Follow up plan

Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months0029

Prescription

See Below (scroll down)Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials

References

Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.

Grammar

EA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age ___________

Date: _______________

RX ______________________________________

SIG:

Dispense: ___________ Refill: _________________

No Substitution

Signature:____________________________________________________________