Clear chronological narrative of present illness

SOAP format for Typhon Clinical notes

Brief but concise. Include only those that are appropriate to the problem

S: a) Clear chronological narrative of present illness (this is the reason for consulting). Include onset {number of hours or days or weeks or months or years prior to consult (PTC)} of the problem

b) Signs and symptoms. Describe the primary Sx in terms of location, quality, severity, timing (onset, duration, frequency), setting, factors that worsened or relieved the problem, other associated manifestations

c) Setting the problem developed (was patient asleep when it happened, walking, etc)

d) Any treatments/Rx or non Rx/home remedies with doses and frequency of use and how that impacted the problem

e) As appropriate, include negative data that may have diagnostic significance

f) As appropriate, include the impact of the complaint to the patient’s life, his understanding of the problem, etc.

Include the following only if pertinent to the problem and will help lead to the Dx:

a) Allergies, if due to meds, include the specific reaction

b) Past Hx, Personal/Social Hx, Family Hx

c) ROS: include, only if patient has complaints that were not mentioned in the HPI but pertinent to the problem. Otherwise, just document it as:

ROS: reviewed

– this means, you asked the patient the list of organ systems but nothing new came up from your interview

ROS includes the following:

General:

Skin:

Head:

Eyes:

Ears:

Nose and Sinuses:

Mouth and Throat:

Neck:

Breasts:

Respiratory:

Cardiac:

Gastrointestinal:

Urinary:

Genital:

Peripheral Vascular:

Musculoskeletal:

Neurologic:

Hematologic:

Endocrine:

Psychiatric:

O:

Note: for Typhon clinical notes, there is no need to include all systems, UNLESS, patient’s visit is for annual PE.

For all other cases, you must include a) General survey; b) VS, include if appropriate the ht, wt, BMI; c) the organ system/s pertinent and related to the primary problem; d) heart; and e) lungs.

Sequence of PE:

General Survey

VS

Skin

HEENT

Lungs: Anterior thorax, Breast palpation

Heart

GI: document in order of examination – inspection, auscultation, palpation/percussion

Extremities

Genitalia and Rectum

Nervous system

Lab/Diagnostic test results

A: diagnosis. Include other considerations (DDx) if appropriate

P: medications, dose, frequency

Labs and diagnostic test/s requested

Referrals

Health teachings, include meds, diet, exercise –as appropriate to the case

When to call clinic if not responding to Mx or with SE’s to meds given

When is next fl-up

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