Clinical Assessment and Health Records

Overview
A comprehensive SOAP note documents a full clinical picture, typically during an annual (wellness or preventative) exam, new patient intake, or complex follow-up. It includes all systems, preventative care, chronic conditions, and screening assessments. Use professional, concise language. Include all that was discussed during the encounter. Do not document “normal findings, or WNL”.
When completing your SOAP note:
• Your patient should be at least 50 years old and have a minimum of one chronic health problem.
• Be sure to complete ALL parts of the plan, whether they apply or not.
• You should use at least two scholarly resources to obtain the necessary clinical information to develop the assessment and treatment plan. You may use your Seidel textbook and one other scholarly reference of your choice. Format your references in APA format.
Subjective:
• Chief Complaint: In the patient’s words – “I am here for my annual wellness exam” or “I’m here to establish care as a new patient”
• HPI- Narrative summary of the primary concerns. Use OLDCARTS if the patient has any new “symptoms.”
ROS
• Include all major systems
Meds: include all prescriptions, herbal supplements and OTC
PMH: Chronic conditions, hospitalizations, relevant illnesses
PSH: Include all past surgeries
Allergies: Include drug and nondrug allergies with reactions
Family History: Immediate relatives and relevant heredity
Social History: smoking, alcohol, drug use, sexual activity, occupation, living situation, exercise, diet, stress
Objective:
• Vital signs: All current, + height, weight, BMI
• Physical Exam: Include all systems examined, even if unremarkable
• Diagnostics (any reviewed or performed)
Assessment:
• List each chronic diagnosis with the appropriate ICD-10 code.
• For each, include a brief rationale (symptom evidence, labs, exam findings)
Plan:
• Therapeutics (all descriptions, refill, OTC)
• Diagnostics: Labs, imaging, in-office tests ordered
• Referrals: Specialists, behavioral health, nutrition, etc
• Preventative Health: Include all age-appropriate screenings
• Lifestyle Counseling (diet, exercise, smoking cessation, etc.)
• Follow up Specify timeline and reason (3-month DM check up, 2 week BP follow up, etc)