Liesl SOAP 3

Introduction

This note is transcribed using Empathia Medical Scribe. There may be errors of recognition. [Document the type of visit, telehealth or in person visit]

Subjective

[For each issue, provide detailed information including onset, location, severity, exacerbating factors, relieving factors, treatments tried and any associated symptoms. Write this as bullet points] For example: 1. [Issue 1] - [Detailed description] 2. [Issue 2] - [Detailed description]

Past Medical History

- [List each medical condition as a separate bullet point, ensuring to include any chronic conditions, medications, allergies, operations, alcohol use, smoking, recreational substance use, family history, vaccine history, social history, provide comprehensive information such as lifestyle, occupation, living situation, and any other relevant social factors. (Only include information that is discussed in the transcript.) Exclude lab results, imaging results, and special investigation results. Include examples of what should be included, such as 'Chronic asthma managed with inhalers' or 'Family history of diabetes'. Exclude examples like 'Blood test results from 2023' or 'MRI findings'. If there is no information then leave out the heading.]

Subjective

[For each issue, provide detailed information including onset, location, severity, exacerbating factors, relieving factors, treatments tried and any associated symptoms. Write this as bullet points] For example: 1. [Issue 1] - [Detailed description] 2. [Issue 2] - [Detailed description]

Objective

[Document the patient's vital signs, including weight, height, head circumference, and any changes since the last visit. Calculate the BMI if weight and height are mentioned, using metric units. Present the information in a bulleted list format. For example: - Weight: [Current Weight] kg (weight change of [Weight Change] kg since [Previous Date] when weight was [Previous Weight] kg)] [Document completed lab results, imaging reports, special investigation results, include previous and present lab results. For example: - Current lab result: [Current lab result], [previous same lab result]-[previous same lab result date] [Document all physical examination findings that are not better included under the ENT, Respiratory, CVS, Abdomen, CNS, Rectal exam, Speculum, Breast, and Bimanual sections. Ensure that examination findings are placed under their appropriate sections and not repeated here if already documented elsewhere.] [If I am going to look in your ears is said, always write: - ENT: Normal tympanic membranes, Normal ear canals, Normal pharynx, Normal Uvula, No enlarged cervical lymph nodes, No postnasal drip, No facial tenderness, No tenderness over mastoids, No nasal congestion, No nasal discharge, No drooling. (Make adjustments for abnormal and additional findings. If no ENT examination is performed exclude this section heading.)] [If I am going to listen to your breathing is said, always write: - Respiratory: Good ventilation bilaterally, No respiratory distress, No wheezes, No crepitations, No rubs, No stridor. (Make adjustments for abnormal and additional findings. If no Respiratory examination is performed exclude this section heading.)] [If I am going to listen your heart is said, always write: - CVS: Normal S1, S2, No murmurs, Regular rhythm, No carotid bruits, No peripheral edema. (Make adjustments for abnormal and additional findings. If no cardiovascular examination is performed then exclude this section heading.)] [If I am going to do a neurological examination is said, always write: - CNS: Pupils equal and reactive, Facial symmetry, Normal taste and smell, Normal hearing and vision, Normal facial sensation, Normal tongue movements, Normal swallowing, Normal eye movements, Normal cognitive function, Normal gait, Normal strength, Normal sensation. (Make adjustments for abnormal and additional findings. If no central nervous system examination is performed then exclude this section heading.)] [If I am going to do a rectal examination is said, always write: - Rectal Exam: No perianal masses, No sinus tracts, No redness around rectum, Normal sphincter tone, No masses in rectum, Normal prostate (only include information about the prostate if the patient is male), No blood on glove. (Make adjustments for abnormal and additional findings. If no rectal examination is performed then exclude this section heading.)] [If I am going to do speculum examination is said, always write: - Speculum Exam: Normal Cervix no cervical ectropion, Normal vaginal walls, Normal physiologic discharge.(Make adjustments for abnormal and additional findings. If no speculum examination is performed then exclude this section heading.)] [If I am going to examine your breasts is said, always write: - Breast Exam: No skin changes, Breasts symmetrical, No redness, No nipple discharge or other nipple pathology, No enlarged axillary lymph nodes, No breast tenderness, No palpable masses.(Make adjustments for abnormal and additional findings. If no breast examination is performed, exclude this section heading.)] [If I am going to do a bimanual examination is said, always write: - Bimanual pelvic exam: No cervical excitation tenderness, No suprapubic tenderness/ masses, No adnexal tenderness/ masses, No pelvic prolapse. (Make adjustments for abnormal and additional findings. If no bimanual examination is performed then exclude this section heading)]

Objective

[Document the patient's vital signs, including weight, height, head circumference, and any changes since the last visit. Calculate the BMI if weight and height are mentioned, using metric units. Present the information in a bulleted list format. For example: - Weight: [Current Weight] kg (weight change of [Weight Change] kg since [Previous Date] when weight was [Previous Weight] kg)] [Document completed lab results, imaging reports, special investigation results, include previous and present lab results. For example: - Current lab result: [Current lab result], [previous same lab result]-[previous same lab result date] [Document all physical examination findings that are not better included under the ENT, Respiratory, CVS, Abdomen, CNS, Rectal exam, Speculum, Breast, and Bimanual sections. Ensure that examination findings are placed under their appropriate sections and not repeated here if already documented elsewhere.] [If I am going to look in your ears is said, always write: - ENT: Normal tympanic membranes, Normal ear canals, Normal pharynx, Normal Uvula, No enlarged cervical lymph nodes, No postnasal drip, No facial tenderness, No tenderness over mastoids, No nasal congestion, No nasal discharge, No drooling. (Make adjustments for abnormal and additional findings. If no ENT examination is performed exclude this section heading.)] [If I am going to listen to your breathing is said, always write: - Respiratory: Good ventilation bilaterally, No respiratory distress, No wheezes, No crepitations, No rubs, No stridor. (Make adjustments for abnormal and additional findings. If no Respiratory examination is performed exclude this section heading.)] [If I am going to listen your heart is said, always write: - CVS: Normal S1, S2, No murmurs, Regular rhythm, No carotid bruits, No peripheral edema. (Make adjustments for abnormal and additional findings. If no cardiovascular examination is performed then exclude this section heading.)] [If I am going to do a neurological examination is said, always write: - CNS: Pupils equal and reactive, Facial symmetry, Normal taste and smell, Normal hearing and vision, Normal facial sensation, Normal tongue movements, Normal swallowing, Normal eye movements, Normal cognitive function, Normal gait, Normal strength, Normal sensation. (Make adjustments for abnormal and additional findings. If no central nervous system examination is performed then exclude this section heading.)] [If I am going to do a rectal examination is said, always write: - Rectal Exam: No perianal masses, No sinus tracts, No redness around rectum, Normal sphincter tone, No masses in rectum, Normal prostate (only include information about the prostate if the patient is male), No blood on glove. (Make adjustments for abnormal and additional findings. If no rectal examination is performed then exclude this section heading.)] [If I am going to do speculum examination is said, always write: - Speculum Exam: Normal Cervix no cervical ectropion, Normal vaginal walls, Normal physiologic discharge.(Make adjustments for abnormal and additional findings. If no speculum examination is performed then exclude this section heading.)] [If I am going to examine your breasts is said, always write: - Breast Exam: No skin changes, Breasts symmetrical, No redness, No nipple discharge or other nipple pathology, No enlarged axillary lymph nodes, No breast tenderness, No palpable masses.(Make adjustments for abnormal and additional findings. If no breast examination is performed, exclude this section heading.)] [If I am going to do a bimanual examination is said, always write: - Bimanual pelvic exam: No cervical excitation tenderness, No suprapubic tenderness/ masses, No adnexal tenderness/ masses, No pelvic prolapse. (Make adjustments for abnormal and additional findings. If no bimanual examination is performed then exclude this section heading)]

Assessment

[Provide a list of differential diagnoses and current known diagnoses in point form. Ensure clarity and conciseness in listing the diagnoses. Clearly distinguish between differential diagnoses and confirmed current diagnoses.]

Assessment

[Provide a list of differential diagnoses and current known diagnoses in point form. Ensure clarity and conciseness in listing the diagnoses. Clearly distinguish between differential diagnoses and confirmed current diagnoses.]

Plan

[Outline the plan for managing the patient's issues, including medication adjustments, orders for further lab tests, orders for further special investigations and any prescriptions provided.] For example: - [Action 1] - [Action 2] - Prescription provided for [Medication/Adjustment]

Plan

[Outline the plan for managing the patient's issues, including medication adjustments, orders for further lab tests, orders for further special investigations and any prescriptions provided.] For example: - [Action 1] - [Action 2] - Prescription provided for [Medication/Adjustment]