Compose a progress note using the SOAP note format. The written progress note must be completed even if a progress note was documented in the electronic medical record (EMR).
Download and print the word document Hospital Progress Note TemplateLinks to an external site.. Use the Hospital Progress Note TemplateLinks to an external site. to compose the progress note. The note must be legible, completed independently, and in hand-written format. Include the following 8 components (see rubric for detailed information regarding each component):
(S) pertinent subjective information
(O) pertinent objective information
(A) pertinent assessment information
(A) list of working diagnoses or active problems being worked up, monitored, or treated
(A) identify the clinical status (improving, worsening, no change) for each diagnosis or problem identified and supporting information, if applicable
(P) plan for each diagnosis or problem, including rationale
Format
A brief and concise account of pertinent data consistent with subjective (S) information.
2. A brief and concise account of pertinent data consistent with objective (O) information.
3. A brief overview of pertinent assessment information (A).
4. A list of working diagnoses or active problems that are being worked up, monitored, or treated (A).
5. A statement of clinical status (improving, worsening, no change) for each diagnosis or problem identified and supporting information, if applicable (A).
6. A plan for each diagnosis or problem, including rationale (P).
7. Format (written (not typed) on the required template; handwriting is legible and language/abbreviations are consistent with standards for hospital documentation)
case: 58 y hispanic m with pmh dm2 poorly controlled reported to ed c/o swelling and redness over the right pinky toe to down anterior foot was on po augmentine from from his primary , due to minimal improvement was send to hospital by pcp .
pmh: dm
alchol use: social drinker
drug and smoking : denies
allergies:nka
occupation:works in a farm
home medication: farziga 10mg daily
x ray : concer for soft tisuue swelling in the moderate forefoot and fifth and fourth toe
mri: showed acute osteomyelitis of the small toe distal phalanx,early osteomyelitis of the small toe proximal phalanx and a phlegmon surronding the small toe and fifth metatarsophalangeal joint with small effusion of the mtp fifth didgit.
arterial ultraound negative for occulsion
consult: ID and podiatry
Medication: vancomycoin 1.75gm q24
ceftriaxone 2gm q24
insulin lispro high sliding scale sub q achs
insulin humolog mix 75/25 10units ac bk subq
lovenox 40mg subq daily
tramdol 50mg po q6 prn
bendryl 25mg prn q4
miralax 17gm daily prn
hydarlazine 10mg q 4 for systolic >170 prn
labs: wbc: 11.8 from 12.1
rbc: 4.52 from 4.69
hgb: 13.2 from 13.6
hct 37.6 from 39.2
plat: 282 from 245
sodium:135
k : 3.9
chloride:109
co2: 24
anion:
24
bun:9
cret:0.74
gfr:>=60
glucose: 156
osmolality :273
hba1c 10.5
crp:196
plan amputation by podiatry tomorrow
