Posted: October 29th, 2020

Episodic SOAP Note : 5 Important Points to Note

Episodic SOAP Note

S. S. 65-year-old Indian female present to the office with c/o back pain and left hip severe painHx R breast CA treated with chemo and Radiation, HTN CAD CHF Hypothyroid COPD afib TIA and recent insomnia hx of falls

Episodic SOAP Note : MedscoumadinmetoprololLasixLevothyroxineColaceentrestotramadol 25mg BID PRN pain (pt reported this dose is not working)trazadone mg QHSSx hx hysterectomy, R breast mastectomy,Bone density scan was done Dx osteopeniaTreatment

Fosamax Q weeklyIncrease tramadol 50mg BID PRN pain Episodic Visit: Musculoskeletal Focused NoteFor this Assignment, you will work with a patient with a musculoskeletal condition that you examined during the last three weeks.

You will complete your third Episodic/Focused Note Template Form for this course where you will gather patient information, relevant diagnostic and treatment information as well as reflect on health promotion and disease prevention in light of patient factors such as age, ethnic group, previous medical history (PMH), socio-economic, cultural background, etc.

In this week’s Learning Resources, please review the Focused Note resources for guidance on writing Focused Notes..To prepare:• Use the Episodic/Focused Note Template found in the Learning Resources for this week to complete this assignment.

• Select a patient that you examined during the last three weeks based on musculoskeletal conditions. With this patient in mind, address the following in a Focused Note:Assignment:• Subjective: What details did the patient provide regarding her personal and medical history?

• Objective: What observations did you make during the physical assessment?• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. 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, including alternative therapies?

Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. • Reflection notes: What would you do differently in a similar patient evaluation?

episodic soap note
Medicine, age, health care and people concept – Photo of doctor or nurse with clipboard writing prescription for senior woman at hospital or home. Female Nurse writing on clipboard while interacting with a patient in hospital. Nurse Visiting Senior woman For Check Up. Young nurse and elderly woman at home. Doctor receiving patient registration form in hospital

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