Description
Review the Focused Note Checklist provided in this week’s Learning Resources and consider how you will develop your Focused Note for this week’s Assignment. Use the Focused SOAP Note Template found in the Learning Resources for this week to complete this Assignment. Select a patient with gastrointestinal or genitourinary condition that you examined during the last 3 weeks. With this patient in mind, address the following in a Focused Note. Assignment Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies. Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues. Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 codes for the diagnosis. What was your primary diagnosis and why? Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
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PRAC 6541: Primary Care of Adolescents and Children
This is a 10-year-old female accompanied by her mother for acute diarrhea and
vomiting for the past 3 days. The mother verbalized concerns that the patient had
4 to 6 episodes of vomiting in 24 hours, and 5 episodes of diarrhea in the last 24
hours. The mother verbalized given home remedies such as bush tea with no
relieve.
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint): This is a brief statement identifying why the patient is here in the
patient’s own words, for instance, “headache,” not “bad headache for 3 days.”
HPI: This is the symptom analysis section of your note. Thorough documentation in this
section is essential for patient care, coding, and billing analysis. Paint a picture of what
is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to
start every HPI with age, race, and gender (e.g., 34-year-old African-American
male). You must include the seven attributes of each principal symptom in paragraph
form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the
following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable
but not completely better
Severity: 7/10 pain scale
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PRAC 6541: Primary Care of Adolescents and Children
Current Medications: Include dosage, frequency, length of time used, and reason for
use. Also include over-the-counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a
description of what the allergy is (e.g., angioedema, anaphylaxis). This will help
determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major
illnesses, and surgeries. Depending on the CC, more info is sometimes needed.
Soc & Substance Hx: Include occupation and major hobbies, family status, tobacco
and alcohol use (previous and current use), and any other pertinent data. Always add
some health promotion questions here, such as whether they use seat belts all the time
or whether they have working smoke detectors in the house, the condition of the living
environment, text/cell phone use while driving, and support systems available.
Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic
illnesses. The reason for death of any deceased first-degree relatives should be
included. Include parents, grandparents, siblings, and children. Include grandchildren if
pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression).
History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual—
current and historical).
Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant
(yes or no), nursing/lactating (yes or no), contraceptive use (method used), types of
intercourse (oral, anal, vaginal, other), and any sexual concerns.
ROS: This covers all body systems that may help you include or rule out a differential
diagnosis. You should list each system as follows: General: Head: EENT: and so forth.
You should list these in bullet format and document the systems in order from head to
toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears,
Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
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PRAC 6541: Primary Care of Adolescents and Children
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No
palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain
or blood.
GENITOURINARY: Burning on urination. Pregnancy. LMP: MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or
tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or
polydipsia.
REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or
penile discharge. Not sexually active.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam: From head to toe, include what you see, hear, and feel when conducting your
physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and
history. Do not use “WNL” or “normal.” You must describe what you see. Always
document in head-to-toe format (i.e., General: Head: EENT:).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop
the differential diagnoses (support with evidenced and guidelines).
A.
Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or
presumptive diagnosis should be at the top of the list. For each diagnosis, provide
supportive documentation with evidence-based guidelines.
P.
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PRAC 6541: Primary Care of Adolescents and Children
Includes documentation of diagnostic studies that will be obtained, referrals to other
health care providers, therapeutic interventions, education, disposition of the patient,
and any planned follow-up visits. Each diagnosis or condition documented in the
assessment should be addressed in the plan. The details of the plan should follow an
orderly manner. Also included in this section is the reflection. The student should
reflect on this case and discuss whether or not they agree with their preceptor’s
treatment of the patient and why or why not. What did they learn from this case? What
would they do differently?
Also include in your reflection a discussion related to health promotion and disease
prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and
other risk factors (e.g., socioeconomic, cultural background).
References
You are required to include at least three evidence-based, peer-reviewed journal
articles or evidenced-based guidelines that relate to this case to support your
diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition
formatting.
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