Assignment: Online Expanded Typhon Case Logs & Soap Notes

Expanded Typhon Case Logs (SOAP)

• Create 10 different Soap notes addressing different Geriatric health issues The soap notes must address the Geriatric 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 health issues

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.​

Assignment: Online Expanded Typhon Case Logs & Soap Notes 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: Assignment: Online Expanded Typhon Case Logs & Soap Notes

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.

Assignment: Online Expanded Typhon Case Logs & Soap Notes 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.

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. Assignment: Online Expanded Typhon Case Logs & Soap Notes

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. Assignment: Online Expanded Typhon Case Logs & Soap Notes

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. Assignment: Online Expanded Typhon Case Logs & Soap Notes

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: AVOID USING”WNL,Normal Findings, write out all findings even if its normal

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 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. Assignment: Online Expanded Typhon Case Logs & Soap Notes

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: Assignment: Online Expanded Typhon Case Logs & Soap Notes

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 dosing information, including quantity and number of refills for any new or refilled medications. Pay attention to pediatric dosage.

Reminder: Clinical documentation is confidential.

Educational: information clients need in order to address their health problems. Include follow- up 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.

Assignment: Online Expanded Typhon Case Logs & Soap Notes SOAP Note Evaluation Rubric

Criterion	Highly Proficient	Proficient	Marginally Proficient	Approaching Proficiency	Not Proficient	Not evident
ICD-10 Code	ICD-10 Code provided with appropriate modifiers congruent with the clinical information provided	ICD-10 Code provided that is congruent with clinical information provided but fails to demonstrate appropriate modifiers	ICD-10 Code provided with limited clinical information detail	ICD-10 Code provided without clinical information	ICD-10 code provided that is not congruent with the clinical information provided	ICD-10 Code not provided
Faculty Feedback:
CPT Code	N/A	Clinical information provided is congruent with and supports the CPT Code identified in the encounter Assignment: Online Expanded Typhon Case Logs & Soap Notes	Clinical information provided is either not congruent with or does not support the CPT Code identified in the encounter	N/A	Clinical information provided is not congruent with and does not support the CPT Code identified in the encounter	CPT Code not provided
Faculty Feedback:
Subjective Data	All elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are adeptly documented and demonstrate consistent information	All elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are appropriately documented and	All elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are satisfactorily documented but do not demonstrate	All elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are either not satisfactorily documented or do	All elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are not satisfactorily documented and do not demonstrate	No elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are provided in the assignment

 

	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 Assignment: Online Expanded Typhon Case Logs & Soap Notes	consistent information across all aspects represented
Faculty Feedback:
Objective Data	All elements of objective data are adeptly documented and demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS	All elements of objective data are appropriately documented and demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS	All elements of objective data are satisfactorily documented but do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS	All elements of objective data are either not satisfactorily documented or do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS	All elements of objective data are not satisfactorily documented and do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS	No elements of objective data are provided in the assignment
Faculty Feedback:
Assessment	Assessment designations and other elements in this section are adeptly documented and demonstrate congruence with information documented in the CC, HPI, PMH, ROS, and the objective data Assignment: Online Expanded Typhon Case Logs & Soap Notes	Assessment designations and other elements in this section are appropriately documented and demonstrate congruence with information documented in the CC, HPI, PMH, ROS, and the objective data	Assessment designations and other elements in this section are satisfactorily documented but do not demonstrate congruence with information documented in the CC, HPI, PMH, ROS, and the objective data	Assessment designations and other elements in this section are either not satisfactorily documented or do not demonstrate congruence of information documented in the CC, HPI, PMH, ROS, and the objective data	Assessment designations and other elements in this section are not satisfactorily documented and do not demonstrate congruence of information documented in the CC, HPI, PMH, ROS, and the objective data	Assessment designations and other elements in this section are not provided in the assignment
Faculty Feedback:

 

Plan	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 Assignment: Online Expanded Typhon Case Logs & Soap Notes	Elements of the plan are appropriately documented, demonstrate application of current clinical practices for the identified assessment designations, and demonstrate congruence of information across all aspects represented	Elements of the plan are satisfactorily documented but either do not demonstrate application of current clinical practices for the identified assessment designations, or do not demonstrate congruence of information across all aspects represented	Elements of the plan are either not satisfactorily documented, or do not demonstrate application of current clinical practices for the identified assessment designations, or do not demonstrate congruence of information across all aspects represented	Elements of the plan are not satisfactorily documented, do not demonstrate application of current clinical practices for the identified assessment designations, and do not demonstrate congruence of information across all aspects represented	Elements of a plan are not provided in the assignment
Faculty Feedback: