After watching video 1, submit a medical note that includes the Chief Concern and History of Present Illness. Use the same general structure and rubric as last week. These details are copied below for your convenience.
Watch or review the following videos:
Video 1: https://www.youtube.com/watch?v=Tn3q8n06EtA
Assignment Overview:
Assignments you are asked to submit SOAP notes, or parts of SOAP notes. This Assignment focuses on the “S” or Subjective part of the note. The assignment is worth 30 points.
The University of California at San Diego, UCSD School of Medicine, provides an incredibly comprehensive resource for graduate medical students learning history taking and physical examination skills. Click here to access this link (https://meded.ucsd.edu/clinicalmed/introduction.html). Medical students spend the first two or so years learning these skills and spend the final two years (during their clinical rotations) refining them for applied use in various medical settings.
This week we will again only focus on the Chief Concern and History of Present Illness (CC & HPI). You are welcome to submit additional sections or an entire note if you desire.
Using the SOAP format, please create a portion of the SOAP note for a common clinical case seen in the outpatient setting or Emergency Department. You will make up the details of your case entirely. Use your imagination and create a SOAP note based on a unique clinical encounter. You may utilize anything at all for inspiration. Many of the clinical vignettes in the textbook by Chabner could serve as source material. You can also use a case from a movie or TV show, or you may use your professional or personal experiences. Please do not disclose any obvious PHI (change names, etc.)
Below are the 25 most common diagnoses for outpatient visits; you may use these diagnoses for inspiration if you like. This list is generated from billing codes that providers use to get reimbursed for the care they provide. The associated billing codes are called ICD-10 codes, and they are used throughout the healthcare system across all medical specialties and types of providers.
Hypertension I10
Hyperlipidemia E78.5
Diabetes E11.9
Back pain M54.5
Anxiety F41.9
Obesity E66.9
Allergic rhinitis J30.89
Reflux esophagitis K21.9
Upper Respiratory Infection J06.9
Hypothyroidism E03.9
Visual refractive errors H52.7
General medical exam Z00.00
Osteoarthritis M19.9
Fibromyalgia/myositis M79.7
Fatigue R53.83
Pain in joint M25.50
Acute laryngopharyngitis J02.9
Acute maxillary sinusitis J01.00
Major depressive disorder F33.9
Acute bronchitis J20.9
Asthma J45.909
Depressed mood F34.1
Nail fungus B35.1
Coronary atherosclerosis I25.1
Urinary tract infection N39.0
Remember the characteristics of the HPI and address all of these in your submitted note (https://meded.ucsd.edu/clinicalmed/introduction.html.). This should be the most important focus of your note.
Onset: When did the symptoms start?
Duration: How long has this condition lasted? Is the problem getting better, worse, or staying the same? If it is changing, what has been the rate of change? Is it similar to a past problem? If so, what was done at that time?
Severity/Character: How bothersome is this problem? Does it interfere with your daily activities? Does it keep you up at night? Try to have them objectively rate the problem. If they are describing pain, ask them to rate it from 1 to 10 with 10 being the worse pain of their life, though first find out what that was so you know what they are using for comparison (e.g. childbirth, a broken limb, etc.). Furthermore, ask them to describe the symptom in terms with which they are already familiar. When describing pain, ask if it’s like anything else that they’ve felt in the past. Knife-like? A sensation of pressure? A toothache? If it affects their activity level, determine to what degree this occurs. For example, if they complain of shortness of breath with walking, how many blocks can they walk? How does this compare with 6 months ago?
Location/Radiation: Is the symptom (e.g. pain) located in a specific place? Has this changed over time? If the symptom is not focal, does it radiate to a specific area of the body?
Aggravating/Alleviating Factors: Have they tried any therapeutic maneuvers?: If so, what’s made it better (or worse)? Comment on BOTH aggravating and alleviating factors.
Associated Symptoms: Are there any associated symptoms? Often times the patient notices other things that have popped up around the same time as the dominant problem. These tend to be related. An example is blood in the urine noted when wiping (hematuria) associated with a presenting concern of burning with urination (dysuria).
What do they think the problem is and/or what are they worried it might be?
Why today?: This is particularly relevant when a patient chooses to make mention of symptoms/complaints that appear to be long-standing. Is there something new/different today as opposed to every other day when this problem has been present? Does this relate to a gradual worsening of the symptom itself? Has the patient developed a new perception of its relative importance (e.g. a friend told them they should get it checked out)? Do they have a specific agenda for the patient-provider encounter?
Are the other pertinent negative or positive findings? For example, if someone presents with shortness of breath, the presence or absence of chest pain is pertinent.
Is there relevant Past Medical History (PMH), Social History (SH), or Family History (FH)? Be sure to include this! (it’s part of the Rubric)
Assignment Formatting:
Assignment Formatting:
Remember to include every aspect of the required elements as outlined in the Rubric. Full credit will not be awarded if some components are missing.
A general outline for the Subjective portion of an office note follows, but this is not a rigid requirement:
Patient Name and ID number and DOB (name and 2 identifiers is standard)
Service/Note title (e.g., Outpatient Clinic, Family Medicine Rotation, Office Visit)
Date of visit/note
Your name (you can use a pseudonym if you would like your assignment to be graded anonymously)
Your title (e.g, KIN student, MD, PA-C, PGY-4 ortho resident – be creative)
CC
HPI (include all parameters, see Rubric)
Review of Systems (ROS)*
Past Medical History (PMH)
Past Surgical History*
Medications*
Allergies*
Family History
Social History
* not required in entirety for this Assignment
Grading Rubric:
In this course, you have mastered many new medical terms. This written assignment will allow you to utilize these terms in an appropriate context, specifically in a medical document that is vital to the care of the patient. You are asked to:
construct the Subjective portion of a SOAP note for a clinical case you have created,
distinguish when to use the Medical Terminology that you have acquired vs. plain language or the patient’s words,
consider the appropriate use of evidence-based resources; these are generally reserved for the Assessment and Plan,
demonstrate your ability to communicate using professional norms in the written or digital patient record.
