Soap Note Format : Patient Information

According to Chtourou (2013), a CDI program focuses on enhancing the accuracy of clinical documentation quality which requires a huge input from CDI specialists, heath information management professionals, coders and clinicians to collaborate together to review the quality of documentation reported/captured in order to ensure accuracy and complete of patient’s clinical encounter. As a healthcare provider, medical records that are incomplete or inaccurate often times, compromise the quality of care reporting and inevitably affect the clinical decision support system of the organization including the accuracy of reimbursement. This is reasonable since the CDI program has emerged as a new paradigm to meet the changing needs of maintaining a sound health record documentation across the healthcare industry (Hauger, 2014). Most of the CDI programs have to a great extent concentrated on boosting the Diagnosis-Related Groups (DRGs) installments by securing clinical documentation to support medical complications and co-morbidities (Hauger, 2014).

The patient has no family history of heart disease or diabetes, however both her parents are on medication for high blood pressure. Her paternal grandmother died of breast cancer at age 47. Her maternal grandmother

One afternoon a 67 year-old man presented to the emergency department of a small, rural hospital complaining of severe left leg and hip pain following a fall at home. The patient had no past history of falls. He had a history of impaired glucose intolerance, prostate cancer, hypercholesterolemia and hyperlipidemia. The patient’s current medications were atorvastatin and oxycodone for chronic back pain. The patient stated his pain was ten out of ten on a scale of one to ten with ten being the worst. The left leg appeared shorter than the right, edema was present in the calf, as was ecchymosis and he had limited range of motion. After an evaluation in triage by a registered nurse and a subsequent examination by the emergency department physician, a plan was established to sedate the patient using moderation sedation protocol and perform a manual reduction of the hip.

The patient Matt is a 19-year-old Caucasian male that was admitted to the unit and being treated for lethargy, excessive thirst, recent unexpected weight loss, fever and frequent urination. Patient is uninsured, a college athlete (runs 3-5 miles a day on the cross country team), works 16 hours a week on the night shift, lives with five of males and says his diet consist of fast food, prepackaged meals and admits to having 3-4 beers, 3-4 day a week and has an allergy to penicillin (hives) and sulfa drugs. Patient was treated for a UTI once 3 months ago. The patient’s current vital signs are: temperature of 101.6F, heart rate of 99, respiratory rate of 22, blood pressure of 119/76, SaO2 99% on

12/24/15 Progress Report describes that the patient has right knee pain. The pain is frequent. It is aching and burning in quality. The current pain level is 0/10 and worst pain is 4/10. Bending, squatting, walking, weight bearing, changing clothes and ROM aggravate the pain. Rest, ice,

Based on the progress report dated 03/02/16 by Dr. Ozaeta, the patient has had a right knee corticosteroid injection one week ago. She had to take a Norco yesterday for right knee pain. She saw Dr. Cantrell, who requested 8 additional physical therapy sessions. She has low back discomfort, notable when sitting. She takes nortriptyline and an antihypertensive.

Physical therapy saw the patient, and the result of the examination are as follows; 6/10 left knee pain at rest and during activity (0 no pain, 10 worst pain), manual muscle testing for both upper and lower extremities were 4/5 except left knee flexion/extension 3+/5 due to pain, sensation on both UE/LE were intact to light touch, Stephen requires a moderate assistance of one person for both functional mobility and gait activity. He uses a front wheeled walker up to 35 feet due to decreased balance and antalgic gait from the left knee

Medical Diagnosis: Client was diagnosed with a fractured right tibia bone, and fractured right radial bone. Client has diabetes mellitus type one. Client has history of hypertension and was admitted with chest pain following accident. The client fell off her bicycle while walking her dog.

Based on the progress report dated 08/23/16, the patient complains left knee pain upon walking. Discomfort was described as aching, tingling, intense, severe, continuous, pain, discomfort, increasing with movement and varying with activity. Pain is rated as 5/10 without medications and 4/10 with medications.

The following case scenario is based on a fictitious patient, and it would be use on this paper as a guidance to develop a patient and family teaching plan. The situation: Mrs. Marquez, a 39-year-old Caucasian female was admitted into the Emergency Department due to complains of shortness of breath and anxiety. Patient cannot take deep breaths, appears overweight and denies Allergies to medication. The background: Patient has medical history for panic attacks, atrial fibrillation, and Grand Mal seizures; however, patient is not constantly taking her seizure medication. Patient previously had a cholecystectomy, and smokes 1 pack of cigarettes per day for 12 years. The Assessment: Patient vital signs 98.8° F oral, 109 heart rate, 26 respiratory rate, 150/86 blood pressure, SaO2 97% on room air. Denies pain. Neurological; Patient is 65 inches tall, weighing 246 lbs. She is able to move all extremities with strong pushes and pulls. States her “last seizure was two months ago.” Respiratory; Respirations are even, deep, and rapid. Lungs are clear on auscultation. Cardiac; EKG reveals atrial fibrillation; patient states, “It feels like my heart is racing at times.” Pulses are palpable +3 all extremities; capillary refill is instant. GI; Abdomen soft, no distended, and no tender with bowel sounds present in all four quadrants; skin is intact and warm. Current medications: Dilantin 400mg PO BID, Lexapro 20mg PO daily, Metoprolol 25

Patient Y is a fifty nine year old widow, with a BMI of 29.0kg/m2 (severely overweight). Patient is currently unemployed and lives alone after the passing of her husband in 2008. Patient states that there is a strong family history of heart disease and confirms this by explaining that her father had died at the age of fifty after suffering from chronic heart failure for several years. Patient states that she drinks up to 24 units of alcohol a week and has prevalent past history of smoking.

In the last three weeks my client G was experiencing tingling in his hands, decreased fine motor control in his hands and increased weakness in his back and legs. This all led to decreased mobility and he was not in a wheel chair with limited ambulation (transferring to and from his bed or toilet and walking with PT two times day). This was a drastic change to his ability to care for himself and move about freely. This was impacting his emotionally and physically. Gas expressed embarrassment of having someone to help his to use the toilet and bath him. Due to his decreased mobility and spinal damage, he was losing strength, possibly at risk embolism and

This is 35 year old WM. Patient was seen at UAB ED for UTI and kidney stone on 3/30/2016. Patient was discharged with roboxin and ibuprofen. Patient has a history of Hep C, was told about 12 years ago, and was retested at UAB and HVC was positive. Patient is a current resident at the Villige. Patient has a history of substance abuse, denies current use, last use about 10 days ago. Patient is a current tobacco user, denies use of alcohol or illicit drugs. Patient reports some depressive moods, denies thoughts of suicide or

Current medications include OxyContin 20 mg 1 tablet every 12 hours, Aspirin 325 mg, clopidogrel 75 mg, gabapentin 600 mg, lisinopril 10 mg and Percocet 7.5/325 mg 1tablet every 4 hours.

Health History: A 25-year-old male injured his left knee in a recent skiing accident. The patient stated that he lost his balance because the inner edge of his right ski got caught while skiing. This resulted in the right leg being externally rotated followed by and audible “pop” as he lost footing. By evening, the right knee joint had become swollen, causing intense pain. The primary care physician referred the case to an orthopedist.