Directions: Read over the SOAP note and formulate a primary diagnosis. Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.
- Upload a copy of your completed SOAP note.
- Upload a copy of the evaluation & management score sheet.
Case Study: A 47-year-old African-American man presents to your office for a follow-up visit. He was seen 3 weeks ago for an upper respiratory infection and noted incidentally to have a blood pressure of 164/98 mm Hg. He vaguely remembered being told in the past that his blood pressure was “borderline.” He feels fine, has no complaints, and his review of systems is entirely negative. He does not smoke cigarettes, drinks “a couple of beers on the weekends,” and does not exercise regularly. He has a sedentary job. His father died of a stroke at the age of 69. His mother is alive and in good health at the age of 72. He has two siblings and is not aware of any chronic medical issues that they have. In the office today, his blood pressure is 156/96 mm Hg in his left arm and 152/98 mm Hg in the right arm. He is afebrile, his pulse is 78 beats/min, respiratory rate 14 breaths/min, he is 70-in tall, and weighs 210 lb. A general physical examination is normal.
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GroupSOAPRubricandTemplate.docx
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EvaluationandManagementEMScoreSheet8985-2-1.pdf
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ComprehensiveSOAPNoteExample.doc2.pdf
SOAP NOTE GRADING RUBRIC
Guidelines:
1-Use the case study in the description to complete the assignment. Fill in the missing details for each required section that would be expected for the diagnosis.
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SUBJECTIVE Analysis (0.2 POINT) |
Score received |
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1-Subjective section should include: a-Chief complaint (CC) b-History of present illness (HPI)- All 7 attributes (location, quality, quantity or severity, timing including onset, frequency, and duration, setting in which it occurs, aggravating or relieving factors, and associated symptoms) c-Past history (Medical, Surgical, Obstetric/Gynecology, Psychiatric) d-family history (3 generation pedigree of first-degree relatives, i.e. parents, siblings, children) e. Personal and social history (i.e. sexual history 5p’s) f. Review of systems (ROS, pertinent positives and/or negatives) g. Developmentally appropriate-i.e. developmental history if peds, functional assessment and/or dementia screen if elderly a-Identified and collected the necessary data b-Categorized and organized data using the appropriate format c-Incorporated all pertinent data/facts d- Used proper documentation and proper billing code e- PATIENT’S CULTURE MUST BE NOTED |
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OBJECTIVE (0.2POINT) |
Score received |
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1-Objective section should include: a. General survey b. Vital Signs (including BMI and growth chart if applicable) c. All other necessary body systems d. Diagnostic test if available a. Identified and collected the necessary data b. Categorized and organized data using the appropriate format c.Incorporated all pertinent data/facts d. Used proper documentation and billing code |
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ASSESSMENT (0.2 POINT) |
Score received |
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1- Identified correct diagnosis, ICD-10 code, and correct differential diagnosis a-Filtered relevant data from irrelevant data b.-Interpreted relationships/patterns among data (e.g., noted trends) c.Integrated information to arrive at diagnosis d.Identified risk factors d. Used proper documentation |
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PLAN Analysis (0.2POINT) |
Score received |
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a-Recommended an appropriate plan for each problem b-Included recommendations for non-drug and drug therapy c-Included recommendations for monitoring d- Included health education e- Included followup & referrals f- include cultural considerations of patient care Incorporate the patient’s culture on the demographic section on SOAP notes. |
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FORMAT (0.2 POINT) |
Score received |
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1- APA 2- References Current (atleast two references, one of which needs to be uptodate and the other a clinical practice guideline from a peer reviewed journal article or national organization such as AAFP, ACOG, USPSTF) 3- Writing clear, concise 4- Summary/Conclusion |
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TOTAL: /1 |
SOAP FORMAT & RUBRIC
Initials of Patient:
Patient Age:
Patient Ethnicity:
Initials of Provider:
Clinical Setting:
Patient Status: ____New ____Established
SUBJECTIVE DATA; GRADE RECEIVED: _____
Overall Instructions:
1. Identified and collected the necessary data
2. Categorized and organized data using the appropriate format
3. Incorporated all pertinent data/facts
4. Used proper documentation
5. LIST at the end of your subjective section the billing level : Problem Focused, Expanded problem focused, detailed, comprehensive (use guidelines for new vs. established patient
6. Identify cultural influences on care
FORMAT
Chief Complaint:
History of Present Illness:
Location
Quality
Quantity or Severity
Timing (Onset, Duration, Frequency)
Setting
Aggravating and relieving Factors
Associated Symptoms
Past history (include dates):
PMH
· Chronic illness (date of onset) & hospitalizations (dates) Medications: Dose, route, frequency
· Allergies: Medications, Foods, Other Allergens
PSH
· (Dates, indications, and types of operations)
Past Psychiatric Hx
· (Illness and timeframe, diagnosis, hospitalizations and treatments)
Obstetrical/Gynecological (obstetric history & menstrual history) Obstetrical History
· (Gravida-Para-TPAL)
Menstrual History
· (Menarche, LMP, PMP, regular/irregular, frequency, duration, quality of flow, Menopause, Post-menopausal bleeding, HRT)
Health Promotion/Maintenance: Colonoscopy, Prostate (PSA), BP
check, Cholesterol, Annual Physical, Mammography, PAP, Eye
Exam, Dental etc., Immunizations
Functional Status: ADLs and IADLs
Family History: Alive, Deceased, Age, Diseases, Health Conditions that place patient at risk (ages)
Parents
Siblings
Children
Social History:
Cultural Background
Spiritual History/Religious Affiliation and Practices
Complementary/Alternative Care Practices:
Type of Family (Nuclear, Extended etc.)
Marital Status
Parental Status
Work History
Financial History
Diet
Exercise (Frequency, intensity, Time, Type)
Stress Management
Sleep
Social Support
Sexual history (5ps)
Use of alcohol, smoking, or recreational drugs
Living Arrangements
Travel History
Review of Systems:
Constitutional:
Head/face:
Eyes:
Ears:
Nose:
Mouth/Throat/ Neck:
Respiratory:
Cardiac:
Breast:
GI:
GU:
GYN (female):
Reproductive (Male):
Musculoskeletal:
Skin/Integument:
Psychiatric:
Neuro:
Endocrine:
Hematologic/Lymphatic:
Allergic/Immunologic:
Determine Which LEVEL of HISTORY (Choose one):
Focused HPI (1-3 findings); ROS N.A; PFSH N.A
Expanded HPI (1-3 Findings); ROS 1 or more; PFSH N.A.
Detailed HPI (4 or more findings); ROS 2-9 systems; PFSH one
Comprehensive HPI (4 or more findings or status of 3 or more chronic stable conditions; ROS 10-14; PFSH 2-3 areas
OBJECTIVE DATA; Grade received_____
Overall Instructions:
1. Identified and collected the necessary data
2. Categorized and organized data using the appropriate format
3. Incorporated all pertinent data/facts
4. Used proper documentation
5. LIST at the end of your subjective section the billing level : Problem Focused, Expanded problem focused, detailed, comprehensive (use guidelines for new vs. established patient
FORMAT:
Vital Signs:
Oxygen Saturation:
Ht:
Wt:
BMI:
Constitutional:
General:
Physical Examination:
Head/face:
Eyes:
Ears:
Nose:
Mouth/Throat/ Neck:
Respiratory:
Cardiac:
Breast:
GI:
GU:
GYN (female):
Reproductive (Male):
Musculoskeletal:
Skin/Integument:
Psychiatric:
Neuro:
Hematologic/Lymphatic/Immunologic:
Determine Billing LEVEL OF PHYSICAL OBJECTIVE EXAM (choose one):
Focused: 1 body area or organ system (1-5 elements);
Expanded problem focused (2-4 body are or organ system (6-11 elements);
Detailed (5-7 see notes);
Comprehensive (8 organ systems see notes);
Laboratory Data Already Ordered and Available for Review (If not done will go in plan):
Diagnostic Procedures/Data Already Ordered and Available for Review (If not done will go in plan):
ASSESSMENT; GRADE RECEIVED____
1) Main Diagnosis/Problem:
2) Additional Health Problem/Dx:
3) Differential Diagnoses for top diagnoses
4) Identify Risk Factors
PLAN; GRADE RECEIVED________
For Each Diagnosis or Health Problem Identified as Appropriate:
Additional Laboratory Tests or Diagnostic Data Needed
Pharmacologic Management:
Drug, dose, route, frequency, Disp amount
SIG (write like a prescription)
Non-Pharmacologic Management: i.e. hot packs, ice, position changes, TENS unit etc.
Complementary Therapies:
Health Education:
Referrals:
Follow-up Appointment:
For the Encounter Final Level of Decision Making: (give rationale for level which is based on Hx, physical, Decision making); Choose one
Straightforward:
Low Complexity:
Moderate Complexity:
High Complexity:
Billing Level: Give the reason for the Billing by E and Coding as per Number of Systems Reviewed and Level of Physical Exam.
Patient Status: New or established
Level of history
Level of physical (exam)
Level of Medical decision making
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E/M Documentation Auditor’s Instructions
1. History Refer to data section (table below) in order to quantify. After referring to data, circle the entry farthest to the RIGHT in the table, which best describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row to identify the type of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the type of history.
After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5.
HPI: Status of chronic conditions: q 1 condition q 2 conditions q 3 conditions
q Status of 1-2 chronic
Status of 3 chronic
conditions conditionsOR
HPI (history of present illness) elements: q Location q Severity q Timing q Modifying factors
q Quality q Duration q Context q Associated signs and symptoms
q Brief (1-3)
Extended (4 or more)
ROS (review of systems):
q Constitutional q Ears,nose, q GI q Integumentaryq Endo (wt loss, etc) mouth, throat q GU (skin, breast) q Hem/lymph
q Eyes q Card/vasc q Musculo q Neuro q All/immuno q Resp q Psych q All others negative
q None
q Pertinent to problem
(1 system)
q
Extended (2-9 systems)
*Complete
PFSH (past medical, family, social history) areas: q Past history ( the patient’s past experiences with illnesses, operation, injuries and treatments) q Family history (a review of medical events in the patient’s family, including diseases which may be
hereditary or place the patient at risk) q Social history (an age appropriate review of past and current activities)
plete ROS: 10 or more systems or the pertinent positives and/or negatives of
q None
q Pertinent
(1 history area) e**Complet y(2 or 3 histor
areas)
PROBLEM FOCUSED
EXP.PROB. FOCUSED DETAILED -COMPRE
HENSIVE
q
T O
R Y
I S
H
*Com some systems with a statement “all others negative”.
**Complete PFSH: 2 history areas: a) Established Patients – Office (Outpatient) Care; b) Emergency Department.
3 history areas: a) New Patients – Office (Outpatient) Care, Domiciliary Care, Home Care; b) Initial Hospital Care; c) Initial Hospital Observation; d) Initial Nursing Facility Care.
NOTE:For certain categories of E/M services that include only an interval history, it is not necessary to record information about the PFSH. Please refer to procedure code descriptions.
2. Examination
Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination. Circle the type of examination within the appropriate grid in Section 5.
Limited to affected body area or organ system (one body area or system related to problem) PROBLEM FOCUSED EXAM
Affected body area or organ system and other symptomatic or related organ system(s) (additional systems up to total of 7)
EXPANDED PROBLEM FOCUSED EXAM
Extended exam of affected area(s) and other symptomatic or related organ system(s) (additional systems up to total of 7 or more depth than above) DETAILED EXAM
General multi-system exam (8 or more systems) or complete exam of a single organ system (complete single exam not defined in these instructions) COMPREHENSIVE EXAM
A M
E X
Body areas: q Head, including face q Chest, including breasts and axillae q Back, including spine qGenitalia, groin, buttocks
Organ systems:
q
q
Abdomen q Neck Each extremity
q q q 1 body area or system
Up to 7 systems
Up to 7 8 or more systems systems
q Constitutional q Ears,nose, q Resp q Musculo q Psych ) (e.g., vitals, gen app mouth, throat q GI q Skin
q Eyes q Cardiovascular q GU q Neuro q Hem/lymph/imm
PROBLEM FOCUSED
EXP.PROB. FOCUSED DETAILED COMPRE-
HENSIVE
q
– 1 –
q
q
q
3. Medical Decision Making
Number of Diagnoses or Treatment Options
Identify each problem or treatment option mentioned in the record. Enter the number in each of the categories in Column B in the table below. (There are maximum number in two categories.)
Number of Diagnoses or Treatment Options A B X C = D
Problem(s) Status Number Points Result
Self-limited or minor (stable, improved or worsening) Max = 2 1 Est. problem (to examiner); stable, improved 1
Est. problem (to examiner); worsening 2
New problem (to examiner); no additional workup planned
Max = 1
3
New prob. (to examiner); add. workup planned 4
TOTAL Multiply the number in columns B & C and put the product in column D. Enter a total for column D.
Bring total to line A in Final Result for Complexity (table below)
Amount and/or Complexity of Data Reviewed
For each category of reviewed data identified, circle the number in the points column. Total the points.
Amount and/or Complexity of Data Reviewed Reviewed Data Points
1
1
1
1
1
2
2
Review and/or order of clinical lab tests
Review and/or order of tests in the radiology section of CPT
Review and/or order of tests in the medicine section of CPT
Discussion of test results with performing physician
Decision to obtain old records and/or obtain history from someone other than patient
Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider
Independent visualization of image, tracing or specimen itself (not simply review of report)
TOTAL Bring total to line C in Final Result for Complexity (table below)
Use the risk table below as a guide to assign risk factors. It is understood that the table below does not contain all specific instances of medical care; the table is intended to be used as a guide. Circle the most appropriate factor(s) in each category. The overall measure of risk is the highest level circled. Enter the level of risk identified in Final Result for Complexity (table below).Risk of Complications and/or Morbidity or Mortality
Level of Risk
Presenting Problem(s) Diagnostic Procedure(s) Ordered
Management Options Selected
Minimal • One self-limited or minor problem,
e.g., cold, insect bite, tinea corporis
• Laboratory tests requiring venipuncture • Chest x-rays • EKG/EEG • Urinalysis • Ultrasound, e.g., echo • KOH prep
• Rest • Gargles • Elastic bandages • Superficial dressings
Low
• Two or more self-limited or minor problems • One stable chronic illness, e.g., well controlled
hypertension or non-insulin dependent diabetes, cataract, BPH
• Acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis, simple sprain
• Physiologic tests not under stress, e.g.,pulmonary function tests
• Non-cardiovascular imaging studies with contrast, e.g., barium enema
• Superficial needle biopsies • Clincal laboratory tests requiring arterial puncture • Skin biopsies
• Over-the-counter drugs • Minor surgery with no identified risk factors • Physical therapy • Occupational therapy • IV fluids without additives
Moderate
• One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment
• Two or more stable chronic illnesses • Undiagnosed new problem with uncertain prognosis, e.g., lump in breast
• Acute illness with systemic symptoms, e.g., pyelonephritis, pneumonitis, colitis
• Acute complicated injury, e.g., head injury with brief loss of consciousness
• Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test
• Diagnostic endoscopies with no identified risk factors • Deep needle or incisional biopsy • Cardiovascular imaging studies with contrast and no
identified risk factors, e.g., arteriogram cardiac cath • Obtain fluid from body cavity, e.g., lumbar puncture,
thoracentesis, culdocentesis
• Minor surgery with identified risk factors • Elective major surgery (open, percutaneous or
endoscopic) with no identified risk factors • Prescription drug management • Therapeutic nuclear medicine • IV fluids with addititives • Closed treatment of fracture or dislocation without
manipulation
High
• One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
• Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure
• An abrupt change in neurologic status, e.g., seizure, TIA, weakness or sensory loss
• Cardiovascular imaging studies with contrast with identified risk factors
• Cardiac electrophysiological tests • Diagnostic endoscopies with identified risk factors • Discography
• Elective major surgery (open, percutaneous or endoscopic with identified risk factors)
• Emergency major surgery (open, percutane
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