Soap note x 3 (Due 6 hours)
1) Submit 1 document per part
Part 1: Complete the file “Template Soap Note” taking into account the file “Note 1”
Part 2: Complete the “Template Soap Note” taking into account the following information:
Name: LR
Gender: Female
Age: 55 years
Diagnosis: Pure hyperglyceridemia
Chief complain: Pain in the mid-epigastric, chest, and back regions
Part 3: Complete the “Template Soap Note” taking into account the following information:
Name: MK
Gender: Female
Age: 55
Diagnosis: Vitamin D deficiency
Chief complain: Fatigue
2)******APA norms, please use headers
All paragraphs must be narrative and cited in the text- each paragraphs
Bulleted responses are not accepted
Dont write in the first person
Dont copy and pase the questions.
Answer the question objectively, do not make introductions to your answers, answer it when you start the paragraph
Submit 1 document per part
3) It will be verified by Turnitin and SafeAssign
4) Minimum 4 references per part not older than 5 years
9/16/2020 Patient chart – Patient: YAHINMA JIMENEZ DOB: 10/04/1979 PRN: JY850918
https://static.practicefusion.com/apps/ehr/index.html#/PF/charts/patients/af3a8cfe-7a60-4f71-9603-59949cac09a2/summary 1/6
PATIENT
YAHINMA JIMENEZ
DOB 10/04/1979
AGE 40 yrs
SEX Female
PRN JY850918
FACILITY
Beneca Medical Center
T (305) 559-3167
F (786) 482-5707
10511 North Kendall Drive
Suite C201
Miami, FL 33176
Patient identifying details and demographics
FIRST NAME YAHINMA
MIDDLE NAME –
LAST NAME JIMENEZ
SSN –
SEX Female
DATE OF BIRTH 10/04/1979
DATE OF DEATH –
PRN JY850918
RACE –
ETHNICITY –
PREF. LANGUAGE –
STATUS Active patient
CONTACT INFORMATION
ADDRESS LINE 1 10260 SW 96
Terrace
ADDRESS LINE 2 –
CITY Miami
STATE FL
ZIP CODE 33176
CONTACT BY –
EMAIL –
HOME PHONE –
MOBILE PHONE (786) 452-5420
OFFICE PHONE –
OFFICE EXTENSION –
FAMILY INFORMATION
NEXT OF KIN –
RELATION TO PATIENT –
PHONE –
ADDRESS –
PATIENT’S MOTHER’S MAIDEN
NAME
–
Vitals owsheet – YAHINMA JIMENEZ
05/22/20
9:01 AM
Vitals
Weight 270 lb
BMI 45.63
BP 132/81 mmHg
Temperature 98.2 F
Pulse 78 bpm
Respiratory rate 18 bpm
O2 Saturation 98 %
Pain 3
Height 64.5 in
9/16/2020 Patient chart – Patient: YAHINMA JIMENEZ DOB: 10/04/1979 PRN: JY850918
https://static.practicefusion.com/apps/ehr/index.html#/PF/charts/patients/af3a8cfe-7a60-4f71-9603-59949cac09a2/summary 2/6
Diagnoses
Current ACUITY START STOP
(R73.03) Prediabetes Chronic 06/09/2020
Comment: As noted in lab results. 06/02/2020. by Mario Gonzalez-Leyva on 06/09/20
(E78.1) Pure hyperglyceridemia Chronic 06/09/2020
Comment: As noted in lab results. 06/02/2020. by Mario Gonzalez-Leyva on 06/09/20
(E66.01) Morbid (severe) obesity due to excess calories Chronic 05/22/2020
(B36.9) Supercial mycosis, unspecied Chronic 05/22/2020
(E55.9) Vitamin D deciency, unspecied Chronic 05/22/2020
Comment: As noted in lab results. 06/02/2020. by Mario Gonzalez-Leyva on 06/09/20
Medication Ergocalciferol
(L83) Acanthosis nigricans Chronic 05/22/2020
(M54.2) Cervicalgia Chronic 05/22/2020
(Z00.01) Encounter for general adult medical examination with
abnormal ndings
05/22/2020
(Z71.3) Dietary counseling and surveillance 05/22/2020
(Z68.42) Body mass index (BMI) 45.0-49.9, adult 05/22/2020
Historical ACUITY START STOP
No historical diagnoses
Drug Allergies
Active SEVERITY/REACTIONS ONSET
Patient has no known drug allergies
Food Allergies
Active SEVERITY/REACTIONS ONSET
No food allergies recorded
Environmental Allergies
Active SEVERITY/REACTIONS ONSET
No environmental allergies recorded
9/16/2020 Patient chart – Patient: YAHINMA JIMENEZ DOB: 10/04/1979 PRN: JY850918
https://static.practicefusion.com/apps/ehr/index.html#/PF/charts/patients/af3a8cfe-7a60-4f71-9603-59949cac09a2/summary 3/6
Medications
Active SIG START/STOP ASSOCIATED DX
Clotrimazole w/ Betamethasone
(Clotrimazole-Betamethasone) 1-0.05 %
External Cream
1 application topically to
aected area 2 times per day
– –
EScript (veried): 05/22/20 Prescriber: Mario Gonzalez-Leyva SIG: 1 application topically to aected area 2 times per day Rells: 1
Quantity: 45
Diclofenac Sodium (Topical) (Diclofenac
Sodium) 1 % Transdermal Gel
2 grams topically to aected
area 4 times per day
– –
EScript (veried): 07/21/20 Prescriber: Mario Gonzalez-Leyva SIG: 2 grams topically to aected area 4 times per day Rells: 2
Quantity: 1
EScript (veried): 06/30/20 Prescriber: Mario Gonzalez-Leyva SIG: 2 grams topically to aected area 4 times per day Rells: 3
Quantity: 1
EScript (veried): 05/22/20 Prescriber: Mario Gonzalez-Leyva SIG: 2 grams topically to aected area 4 times per day Rells: 2
Quantity: 1
Ergocalciferol 1.25 MG (50000 UT) Oral
Capsule
Take 1 capsule (50,000 units)
by mouth weekly
– Vitamin D deciency
EScript (veried): 06/09/20 Prescriber: Mario Gonzalez-Leyva SIG: Take 1 capsule (50,000 units) by mouth weekly Rells: 5
Quantity: 4
Ibuprofen 600 MG Oral Tablet Take 1 tablet (600 mg) by
mouth 3 times per day with
food or milk as needed
– –
EScript (veried): 06/28/20 Prescriber: Mario Gonzalez-Leyva SIG: TOME UNA TABLETA POR VIA ORAL TRES VECES AL DIA WITH
FOOD OR MILK AS NEEDED Rells: 1 Quantity: 60
EScript (veried): 05/22/20 Prescriber: Mario Gonzalez-Leyva SIG: Take 1 tablet (600 mg) by mouth 3 times per day with food or
milk as needed Rells: 1 Quantity: 60
Ooxacin (Otic) (Ooxacin) 0.3 % Otic
Solution
10 drops into the aected ear
3 times per day for 7 days
– –
EScript (veried): 08/25/20 Prescriber: Mario Gonzalez-Leyva SIG: 10 drops into the aected ear 3 times per day for 7 days Rells:
0 Quantity: 1
Historical SIG START/STOP ASSOCIATED DX
No historical medications recorded
Immunizations
DATE VACCINE SOURCE LOT
NUMBER
EXPIRES COMMENT
No immunizations recorded for this patient.
9/16/2020 Patient chart – Patient: YAHINMA JIMENEZ DOB: 10/04/1979 PRN: JY850918
https://static.practicefusion.com/apps/ehr/index.html#/PF/charts/patients/af3a8cfe-7a60-4f71-9603-59949cac09a2/summary 4/6
Social history
TOBACCO USE RECORDED
Current tobacco use
Non-smoker 05/22/2020
ALCOHOL USE RECORDED
No alcohol use history available for this patient
SOCIAL HISTORY (FREE-TEXT)
Alcohol, social drinker. Coee( less than one cup per day), no drugs.
FINANCIAL RESOURCES RECORDED
No nancial resources recorded for this patient
EDUCATION RECORDED
No education recorded for this patient
PHYSICAL ACTIVITY RECORDED
No physical activity available for this patient
NUTRITION HISTORY RECORDED
No nutrition history available for this patient
STRESS RECORDED
No stress available for this patient
SOCIAL ISOLATION AND CONNECTION RECORDED
No social isolation and connection available for this patient
EXPOSURE TO VIOLENCE RECORDED
No exposure to violence history available for this patient
GENDER IDENTITY
Female
SEXUAL ORIENTATION
Straight or heterosexual
9/16/2020 Patient chart – Patient: YAHINMA JIMENEZ DOB: 10/04/1979 PRN: JY850918
https://static.practicefusion.com/apps/ehr/index.html#/PF/charts/patients/af3a8cfe-7a60-4f71-9603-59949cac09a2/summary 5/6
Past medical history
MAJOR EVENTS
-Cholecystectomy(19 years old)
-Left breast reduction(20 years old)
-Left ectopic pregnancy(2005)
-Uterine broids(2016)
-Abdominoplasty, Breast implant(2016)
Obstetric history: P6D1A4Ectopic pregnancy1
ONGOING MEDICAL PROBLEMS
Morbid obesity
PREVENTIVE CARE
Preventive care
-Mammogram:
Pap smear; negative. Performed 06/03/2020.
Genital culture; Negative. 06/03/2020.
-EKG: Normal sinus rhythm. Performed 05/22/2020.
-Chest X rays:
-HbA1C: Elevated for PreDiabetes. 5.9%. 06/02/2020.
-Tumor markers: Within normal limits. 06/02/2020.
-AAA screening:
-DEXA SCAN:
-FOBT:
-FIT-DNA:
-Spirometry:
-EGD:
-Colonoscopy:
-Eye exam:
-Dental exam: 05/22/2020
-Flu Vaccine:
-Pneumonia Vaccine:
-Shingles Vaccine:
SOCIAL HISTORY
Alcohol, social drinker. Coee( less than one cup per day), no drugs.
Family health history
DIAGNOSIS ONSET DATE
No Family health history recorded
FAMILY HEALTH HISTORY (FREE TEXT)
Father: deceased. heart Attack
Mother: Alive. HTN, Gout
Brother: Alive. Allergies. Renal failure
Daughter: Alive. healthy
Active health concerns
DESCRIPTION EFFECTIVE DATE
No active health concerns recorded
Inactive health concerns
9/16/2020 Patient chart – Patient: YAHINMA JIMENEZ DOB: 10/04/1979 PRN: JY850918
https://static.practicefusion.com/apps/ehr/index.html#/PF/charts/patients/af3a8cfe-7a60-4f71-9603-59949cac09a2/summary 6/6
OBESITY DIET EDUCATION (PROCEDURE)
Start date: 05/22/2020
Status: Performed
WEIGHT CONTROL EDUCATION (PROCEDURE)
Start date: 05/22/2020
Status: Performed
DESCRIPTION EFFECTIVE DATE
No inactive health concerns recorded
Active Goals
DESCRIPTION EFFECTIVE DATE
No active goals recorded
Inactive Goals
DESCRIPTION EFFECTIVE DATE
No inactive goals recorded
Screenings/ Interventions/ Assessments Patient Initials:
Pt. Encounter Number:
Date:
Age:
Sex:
Allergies: Advanced Directives:
SUBJECTIVE
CC:
HPI:
Describe the course of the patients illness:
Onset:
Location:
Duration:
Characteristics:
Aggravating Factors:
Relieving Factors:
Treatment:
PMH
Medication Intolerances:
Chronic Illnesses/Major traumas:
Screening Hx/Immunizations Hx:
Hospitalizations/Surgeries:
Family History:
Social History:
ROS
General
Cardiovascular
Skin
Respiratory
Eyes
Gastrointestinal
Ears
Genitourinary/Gynecological
SOAP NOTE
Nose/Mouth/Throat
Musculoskeletal
Breast
Neurological
Heme/Lymph/Endo
Psychiatric
OBJECTIVE
Weight BMI
Temp
BP
Height
Pulse
Resp
PHYSICAL EXAMINATION
General Appearance
Skin
HEENT
Cardiovascular
Respiratory
Gastrointestinal
Breast
Genitourinary
Musculoskeletal
Neurological
Psychiatric
Lab Tests
Special Tests
Diagnosis
Primary Diagnosis-
Evidence for primary diagnosis should be documented in your Subjective and
Objective exams.
o Differential Diagnoses- Include three diagnoses
PLAN including education
o Plan:
Further testing
Medication
Education
Non-medication treatments
Referrals
Follow-up visits
References
