RDK - SOAP with Details

HISTORY OF PRESENT ILLNESS

[Provide a detailed narrative of the patient's current illness or condition. Include information about symptom control, medication changes with specific doses, associated symptoms, and any other pertinent clinical details. Exclude medical history, surgical history, social history, family history, medications, allergies, and screening unless it is directly related to the history of present illness. Exclude treatment plan, any previous testing not directly related to the history of present illness, and any interpretation of lab results. Abbreviate units for measurements as follows: milligrams (mg), micrograms (mcg), and millimoles per liter (mmol/L).]

Past Medical History

Past Surgical History

Family History

Social History

The Review of Systems

[Convert the 'Review of Systems' section into a narrative format. Ensure that the information flows in a continuous, descriptive manner, rather than in a list format. Include details about each system reviewed, noting any positive or negative findings, and describe the patient's overall health status as it relates to each system.]

Current Medications

[List each medication the patient is currently taking in a bullet-point format. Include the name of the medication, dosage, frequency, and route of administration for each item.]

Allergies

PHYSICAL EXAM

[If any vitals exist with a recorded date matching visit date, display "Vital Signs:" on a new line with the following included only if date matches: Height, Weight, BP, Pulse, Temperature.] [Document each assessed system such as general and any other relevant systems examined. Use a new line for each system. Exclude reported symptoms. Exclude systems that are not assessed.] For example: Vital Signs: Blood Pressure: 120/80, Pulse 75 General: Well appearing, alert and oriented Lungs: Clear to auscultation, normal respiratory effort

Investigations

[Group all investigations performed within 3 months prior to the visit date by the date they were conducted. For each date, list the tests as bullet points. Include: test name and results if available. Do not include: Immunizations and Tests older than 90 days before the visit. If there are no investigations, this section should be omitted.] When there are multiple investigations, each with an associated date, organize the information by grouping all investigations under their respective dates. Present the content in plain text, without using markdown, bold, or any special formatting. For example: 2025-03-13: - Complete Blood Count: xxx - Creatinine: 61 umol/L 2025-02-09: - Potassium: 3.8 mmol/L

ASSESSMENT/PLAN

[For each diagnosis explicitly discussed, list the diagnosis followed by the code in parentheses. Do not include, infer, or assume any diagnoses, plans, or follow-up information that are not clearly and directly discussed. If diabetes is present, list it first and end its plan with “See diabetes flow sheet for details.” If health maintenance is present, list it first and use code 917. Provide a concise assessment and plan only for each diagnosis that is explicitly discussed. Place each diagnosis and its plan on a new line. Include follow-up appointment details only if specific timing is clearly discussed.] For example: Diabetes (250) - See diabetes flow sheet Hypertension (401) - Blood pressure is well controlled. Follow up: 3 months For example: Diabetes (250) - Plan Hypertension (401) - Plan

Billing

Billing: [Code 1], [Code 2], [Code n] [Enter OHIP billing code(s). List codes. No sentences. If chief complaint is well visit and age is 2 to 15 years, use K017. If chief complaint is well visit and age is 16 or 17 years, use K130. If chief complaint is well visit and age is 18 to 64 years, use K131. If chief complaint is Well Visit and age is over 64 years, use K132. If patient has an assessment of diabetes, use K030 as Code 1. If patient has assessment of bipolar disorder, use Q020. If patient has assessment of schizophrenia, use Q021. If code 1 has no value and there is not an assessment of diabetes, use A007. If visit is a phone visit, add K301A. If visit is a video visit, add K300. If visits is for hospital follow up, add code E080. If visit start time is after 5 pm eastern time or visit day is Saturday, add code Q012. If trigger point injections performed add codes G384 and G385x2. If injection of knee, shoulder, or trochanteric bursa performed, add codes G370 and E542. If FIT test ordered, add code Q150. If office urinalysis obtained, add code G010. If office pregnancy test obtained, add code G005. If rapid strep test obtained, add code G014. If EKG obtained, add code G310 and G313. If cryotherapy used, add code Z117. If cryotherapy used for more than 4 actinic keratoses, use code Z119, not Z117. If biopsy without suture performed, add code Z113. If biopsy with suture performed, add code Z116. If incisions and drainage performed, add code Z101. Remove code A007 if code K030 is present.] (For example: Billing: A007, K300) Billing: [Code 1], [Code 2], [Code n] (For example: Billing: A007, K300)

AI Scribe Note

This note was prepared using Empathia AI. Written consent from the patient to use AI scribe.