Instructions:
Review the ‘S’ and ‘O’ data sets accessed through this link.
Data Set SOAP Note download
Construct a discussion that includes the following:
An ‘Assessment’ (‘A’ of a SOAP note) section that is supported by the data sets reviewed.
Assignment of an ICD-10 Code for each diagnosis you included in your ‘A’
Identification of the subjective and objective data for each of the ‘Assessments’ (diagnoses) you included in the ‘A’.
USE THIS LINK AS ONE OF THE RESOURCES AND ALSO USE UPDATED RESOURCES FOR THIS ASSIGNMENT IM ATTACHING SOAP NOTE DATA SET BELOW IS EXAMPLE AND FORMAT PLEASE FOLLOW!
Assessment (A):
Zoster without complications (B02.9)
Subjective: Complaints of rash to the right shoulder; “stabbing” pain to the shoulder area; burning sensation and “itchy”; aggravated with touch and when she gets hot; fever of 100.8; generalized fatigue; denies any prior episode of rash, trauma, injury, illness exposure, or recent exposure to irritants; history of chicken pox; denies receiving shingles vaccine
Objective: Temp 100.6; Unilateral erythematous, maculopapular rash with small areas with developing vesicles to right, posterior, upper shoulder with a dermatomal distribution; The rash is 4cm length by 2cm width
Unspecified hearing loss, right ear (H91.91)
Subjective: Reports hard of hearing to right ear
Objective: Mild hearing deficit to whisper test on right ear
Stress incontinence (N39.3)
Subjective: Reports stress incontinence with cough
Other seborrheic keratosis (L82.1)
Subjective: Small scattered, brown moles to lower back
Objective: Multiple scattered 3mm seborrheic keratosis to lower back
Overweight (E66.3)
Objective: BMI 28.3
Gastro-esophageal reflux disease without esophagitis (K21.9)
Subjective: Reports GERD controlled with medications, denies sore throat or difficulty with swallowing
Type 2 diabetes mellitus without complications (E11.9)
Subjective: History of type 2 diabetes. Average morning glucose is 120. Denies appetite change, hot or cold tolerance, or weight changes.
Osteoarthritis of knee (M17.9)
Subjective: Reports osteoarthritis of bilateral knees
Osteoarthritis of first carpometacarpal joint, unspecified (M18.9)
Subjective: Reports osteoarthritis of bilateral hands
Essential (primary) hypertension (I10)
Subjective: Reports hypertension in PMH
Objective: BP 140/88
Hyperlipidemia, unspecified (E78.5)
Subjective: Reports hyperlipidemia in PMH
References
ICD-10 code lookup. (n.d.). https://icdcodelookup.com/icd-10/codes
Le, P., & Rothberg, M. (2021). Herpes zoster infection. Epocrates. https://online.epocrates.com/diseases/2311/Herpes-zoster-infection/Highlights-Basics
Miller, E. (2017). To code or not to code. https://journal.ahima.org/to-code-or-not-to-code/
THIS IS AN EXAMPLE OF HOW THIS ASSIGNMENTB SHOULD BE DONE WITH INFORMATION
