Create 10 comprehensive notes as an ARNP addressing complex women’s health issues

Expanded Typhon Case Logs (SOAP)
•
Create 10 different Soap notes addressing different women health issues (gynecologic only. The
soap notes must address the Women’s health population only. Please address the ROS(review of
systems),Include OB history if any, and PE(physical examination).In your soap template include
medications, ICD 10 diagnosis codes ,CPT billing codes and referrals if needed.
Notes should vary and address different women health issues such as
PCOS, Amenorrhea, dysmenorrhea, infertility, abnormal pap exams,Fibroids,etc
You may not repeat a topic more than twice.
•
Notes are evaluated by a scoring rubric (see attached)
•
Construction of your SOAP note should be aimed at achieving a score of
“proficient” in each category. Failure to achieve a proficient rating for each of the evaluation criterion,
represented in the rubric, by the end of the course will require revision of the final SOAP note
submitted until successful. Failure to do so results in failure meet the clinical requirements of the
course and failure of the course.
Documentation Requirements
ALL Typhon Case Logs Must Include:
Patient Demographics Section:
o Age
o Race
o Gender
Clinical Information Section:
o Time with Patient
o Consult with Preceptor
o Type of Decision Making
o Student Participation
o Reason for visit
o Chief Complaint
o Social Problems Addressed
Medications Section:
o # OTC Medications taken regularly
o # Prescriptions currently prescribed
o # New/Refilled Prescriptions This Visit
ICD 10 Codes Category:
o For each diagnosis addressed at the visit
CPT Billing Codes Category:
o Evaluation and management code
o – Procedure codes (Pap smear, destruction of lesion, sutures,
vaccination
administration, etc.)
Other Questions About This Case Category:
o Age Range Revised 1/3/19
o Patient type
o HPI
o Patients Primary Language
•
•
•
? Notes are evaluated by a scoring rubric
? Construction of your SOAP note should be aimed at achieving a score of
“proficient” in each category. Failure to achieve a proficient rating for each of the
evaluation criterion, represented in the rubric, by the end of the course will require
revision of the final SOAP note submitted until successful. Failure to do so results in
failure meet the clinical requirements of the course and failure of the course.
SOAP Note Format
All sections should be addressed as pertinent to the presenting chief complaint. Refer to the
rubric and the format below.
*Subjective:
CC: chief complaint – What are they being seen for? This is the reason that the patient sought
care, stated in their own words, or paraphrased.
HPI: history of present illness – use the “OLDCART” approach for collecting data and
documenting findings. [O=onset, L=location, D=duration, C=characteristics,
A=associated/aggravating factors, R=relieving Factors, T=treatment, S=summary]
PMH: past medical history – This should include past illness/diagnosis, conditions, traumas,
hospitalizations, and surgical history. Include dates if possible.
Allergies: State the offending medication/food and the reactions. Medications: Names, dosages,
and routes of administration.
Revised 8/31/18
4
Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV
risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact
health and illness. Financial resources.
Family history: Use terms like maternal, paternal and the diseases and the ages they were
deceased or diagnosed if known.
Health Maintenance/Promotion: (Required for annual wellness or physical exams.)
Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative
Services Task Force (USPSTF) guidelines for age appropriate indicators. This should reflect
what the patient is presently doing regarding the guidelines.
ROS: review of systems – this is to make sure you have not missed any important symptoms,
particularly in areas that you have not already thoroughly explored while discussing the history
of present illness. You would also want to include any pertinent negatives or positives that would
help with your differential diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore
throat, etc.) you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc. While the list
below is provided for your convenience it is not to be considered all-encompassing and you are
expected to include other systems/categories applicable to your patient’s chief complaint.
General: May include if patient has had a fever, chills, fatigue, malaise, etc. Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular Lungs:
GI: gastrointestinal GU: genito-urinary PV: peripheral vascular MSK: musculoskeletal Neuro:
neurological Endo: endocrine Psych:
*Objective:
PE: physical exam – either limited for a focused exam or more extensive for a complete history
and physical assessment. This area should confirm your findings related to the diagnosis. For
acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain
areas such as GYN, Rectal, Abd, etc. All SOAP notes however should have physical
Revised 8/31/18
5
examination of CV and lungs. While the list below is provided for your convenience it is not to
be considered all-encompassing and you are expected to include other systems/assessments
applicable to your patient’s chief complaint. Ensure that you include appropriate male and
female specific physical assessments when applicable to the encounter. Your physical exam
information should be organized using the same body system format as the ROS section.
Appropriate medical terminology describing the objective examination is mandatory.
Gen: general statement of appearance, if there is any acute distress. VS: vital signs, height and
weight, BMI
Skin:
HEENT: head, eyes, ears, nose and throat
Neck:
CV: cardiovascular
Lungs:
Abd: abdomen
GU: genito-urinary
PV: peripheral vascular
MSK: musculoskeletal
Neuro: neurological exam
Diagnostic Tests: This area is for tests that were completed during the patient’s appointment that
ruled the differential diagnosis in or out (e.g. – Rapid Strep Test, CXR, etc.).
*Assessment:
Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each
diagnosis. A statement of current condition of all other chronic illnesses that were addressed
during the visit must be included (i.e. HTN-well managed on medication). Remember the S and
O must support this diagnosis. Pertinent positives and negatives must be found in the write-up.
*Plan:
These are the interventions that relate to each individual diagnosis. Document individual plans
directly after each corresponding assessment (Ex. Assessment- Plan). Address the following
aspects (they should be separated out as listed below):
Diagnostics: labs, diagnostics testing – tests that you planned for/ordered during the encounter
that you plan to review/evaluate relative to your work up for the patient’s chief complaint.
Therapeutic: changes in meds, skin care, counseling Include full prescribing information,
including quantity and number of refills for any new or refilled medications.
Reminder: Clinical documentation is confidential.
Educational: information clients need in order to address their health problems. Include followup care. Anticipatory guidance and counseling.
Consultation/Collaboration: referrals, or consult while in clinic with another provider. If no
referral made was there a possible referral you could make and why? Advance care planning.
SOAP Note Evaluation Rubric
Criterion
Highly
Proficient
ICD-10
Code
ICD-10 Code
ICD-10 Code provided that
provided with is congruent
appropriate
with clinical
modifiers
information
congruent with provided but
the clinical
fails to
information
demonstrate
provided
appropriate
modifiers
Proficient
Marginally
Proficient
Approaching
Proficiency
Not Proficient Not evident
ICD-10 code
ICD-10 Code
provided that
ICD-10 Code
provided with
is not
provided
ICD-10 Code
limited clinical
congruent with
without clinical
not provided
information
the clinical
information
detail
information
provided
Faculty
Feedback:
CPT Code N/A
Clinical
information
provided is
congruent
with and
supports the
CPT Code
identified in
the encounter
Clinical
information
provided is
either not
congruent with
N/A
or does not
support the
CPT Code
identified in
the encounter
Clinical
information
provided is not
congruent with
CPT Code not
and does not
provided
support the
CPT Code
identified in
the encounter
Faculty
Feedback:
All elements of All elements of All elements of All elements of All elements of No elements
subjective data subjective data subjective data subjective data subjective data of subjective
(CC, HPI, PMH, (CC, HPI, PMH, (CC, HPI, PMH, (CC, HPI, PMH, (CC, HPI, PMH, data (CC, HPI,
Allergy
Allergy
Allergy
Allergy
Allergy
PMH, Allergy
Subjective
identification, identification, identification, identification, identification, identification,
Data
Medication
Medication
Medication
Medication
Medication
Medication
Reconciliation, Reconciliation, Reconciliation, Reconciliation, Reconciliation, Reconciliation,
Social History, Social History, Social History, Social History, Social History, Social History,
Family History, Family History, Family History, Family History, Family History, Family History,
Health
Promotion,
and ROS) are
adeptly
documented
and
demonstrate
consistent
information
Health
Promotion,
and ROS) are
appropriately
documented
and
Health
Promotion,
and ROS) are
satisfactorily
documented
but do not
demonstrate
Health
Promotion,
and ROS) are
either not
satisfactorily
documented
or do
Health
Promotion,
and ROS) are
not
satisfactorily
documented
and do not
demonstrate
Health
Promotion,
and ROS) are
provided in
the
assignment
August 2018
across all
aspects
represented
demonstrate
consistent
information
across all
aspects
represented
consistent
information
across all
aspects
represented
not
demonstrate
consistent
information
across all
aspects
represented
consistent
information
across all
aspects
represented
Faculty
Feedback:
Objective
Data
All elements of
All elements of
objective data
objective data
are
are adeptly
appropriately
documented
documented
and
and
demonstrate
demonstrate
consistency
consistency
relative to the
relative to the
information
information
documented
documented in
in the CC, HPI,
the CC, HPI,
PMH, and ROS
PMH, and ROS
All elements of All elements of All elements of
objective data objective data objective data
are
are either not are not
satisfactorily satisfactorily satisfactorily
No elements
documented documented documented
of objective
but do not
or do not
and do not
data are
demonstrate demonstrate demonstrate
provided in
consistency
consistency
consistency
the
relative to the relative to the relative to the
assignment
information information
information
documented in documented in documented in
the CC, HPI,
the CC, HPI,
the CC, HPI,
PMH, and ROS PMH, and ROS PMH, and ROS
Faculty
Feedback:
Assessment
designations
and other
elements in
this section
Assessment are adeptly
documented
and
demonstrate
congruence
with
Assessment
designations
and other
elements in
this section are
appropriately
documented
and
demonstrate
congruence
with
Assessment
designations
and other
elements in
this section
are
satisfactorily
documented
but do not
demonstrate
congruence
Assessment
Assessment
designations designations
and other
and other
elements in
elements in
this section are this section
either not
are not
satisfactorily satisfactorily
documented documented
or do not
and do not
demonstrate demonstrate
congruence of congruence of
Assessment
designations
and other
elements in
this section
are not
provided in
the
assignment
information
documented
in the CC, HPI,
PMH, ROS,
and the
objective data
information
documented in
the CC, HPI,
PMH, ROS, and
the objective
data
with
information
information
information documented in documented in
documented in the CC, HPI,
the CC, HPI,
the CC, HPI,
PMH, ROS, and PMH, ROS, and
PMH, ROS, and the objective the objective
the objective data
data
data
Faculty
Feedback:
August 2018
Plan
Faculty
Feedback:
Elements of
the plan are
adeptly
documented,
demonstrate
application of
current clinical
practices for
the identified
assessment
designations,
and
demonstrate
congruence of
information
across all
aspects
represented
Elements of the Elements of the
Elements of the
Elements of the plan are
plan are either
plan are not
plan are
satisfactorily not
satisfactorily
appropriately documented satisfactorily
documented,
documented, but either do documented, or
do not
demonstrate not
do not
demonstrate
application of demonstrate demonstrate
application of
current clinical application of application of
Elements of
current clinical
practices for
current clinical current clinical
a plan are
practices for
the identified practices for
practices for
not
the identified
assessment
the identified the identified
provided in
assessment
designations, assessment
assessment
the
designations,
and
designations, or designations, or
assignment
and do not
demonstrate do not
do not
demonstrate
congruence of demonstrate demonstrate
congruence of
information
congruence of congruence of
information
across all
information
information
across all
aspects
across all
across all
aspects
represented
aspects
aspects
represented
represented
represented

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