Episodic Visit for Hypertension SOAP Note

QUESTION

Episodic Visit for Hypertension SOAP Note

Student Name:___________________________________________________________

Chief Complaint:

History of Present Illness:

Past Medical History:

Family History:

Social History:

Review of Systems: Constitutional

Eyes:

Ears:

Nose:

Throat and mouth:

Cardiovascular:

Respiratory:

Gastrointestinal:

Musculoskeletal:

Extremities:

Psychiatric:

Physical Exam: Vitals:

Constitutional

Head:

Eyes:

Ears:

Nose:

Throat and mouth:

Neck:

Lungs:

Heart:

Abdomen:

Musculoskeletal:

Extremities:

Skin:

Plan/Management:

Here is an example of a SOAP Note and the information that goes into one for an Episodic visit Example SOAP NoteEpisodic visit.docx

Watch Video 6.1 Follow up exam Adult with Hypertension

**If the link below doesn’t work – log into the online account that I have provided you with. Go to List of Videos and find Video 6.1 – Follow-up Exam: Adult with Hypertension.

https://connect.springerpub.com/content/book/978-0-8261-6454-4/front-matter/fmatter5 (Links to an external site.) to access the videos.

Health Assessment book and videos (https://connect.springerpub.com/content/book/978-0-8261-6454-4?fbclid=IwAR04gn0a8UCD10_nDMH6rpUECvF9yMqgOO5zmxjqHpYyVsXLqqzRw9ZFvTU&implicit-login=true )

Username: [email protected]

Password: Batase1palpa

Fill out the attached in SOAP note form – be sure to type in the required information from watching the video. The table is set up so when you type there should be plenty of space to enter in your notes. Episodic Visit for Hypertension SOAP Note.docx

In this assignment, act as if you are in your precepted clinicals in the room charting for the provider. You have the blank episodic SOAP for you to fill in, and the example one as a guide. Watch the video and chart, hitting pause as you need to and replaying. Fill in as much data as you can from observing this visit, and from your visual assessment.

Here are some tips & examples from this exact video exercise :

Chief Complaint: HTN follow-up

ROS:….Eyes: denies changes in vision…..Ears: n/a

Physical Exam: Vitals: BP, HR, RR, BMI noted as normal per clinician… Ears: not examined Nose: midline Abd: flat, non-distended, BS present x 4

Note that for ears on PE I stated “not examined”. I also did not comment on the external symmetry as we are not able to visualize this on the video well due to her hairstyle. I did comment on her nose sitting midline. On ROS – eyes it is “denies” as she was asked if she had any changes in vision. On the physical assessments, describe the assessment not “wnl” other than the vitals.

You are to complete all data included during this visit. While it is an episodic visit, this is for educational purposes not billing purposes so fill in this document as completely as possible.

Subject	Nursing	Pages	4	Style	APA

Answer

Episodic Visit for Hypertension SOAP Note

Student Name:___________________________________________________________

Chief Complaint: Follow-up on her pressure and cholesterol.

History of Present Illness: Hypertension is being managed well with a good prognosis on follow-up. The patient has incorporated physical exercise. She walks two to three times per week.

Past Medical History: Recent (within 6 months) eye and dental exam. No drug allergies or medication side effects. No other relevant medical history or chronic disease mentioned during history taking and physical examination.

Family History: Not assessed during history taking process.

Social History: A glass of wine once or twice per year. Denies smoking

Review of Systems: Constitutional: Conscious and intact cognitive and language function.

Eyes: No visual problems.

Ears: No hearing problems.

Nose: No nose bleeds. No nasal discharge. No hematemesis or epistaxis.

Throat and mouth: Not throat swelling. Pink lips. No lesions on the lips.

Cardiovascular: The patient has been monitoring her blood pressure levels a couple of times a week. She states that her blood pressure has been 120/80 mmHg. No chest pain.

Respiratory: No shortness of breath. No runny nose. No hoarseness of voice.

Gastrointestinal: No nausea and vomiting.

Musculoskeletal: No muscle or joint pain.

Extremities: Pink skin and no pallor or cyanosis.

Psychiatric: Adequate coping mechanism for stress. Continues to enjoy things that she usually find pleasurable.

Physical Exam: Vitals: Blood pressure, temperature, pulse, respiratory rate, and body mass index noted as normal per the clinician.

Constitutional: Oriented to place, person and time (×3).

Head: Normocephalic head. No headache.

Eyes: Pupil response well to changes in the intensity of light. White sclera. Opening and closing of eye lids. Intact eye movements in all directions. Absence of a squint.

Ears: not examined. No issues with body positioning and balancing.

Nose: Nose in the midline. Breathing through nose and mouth.

Throat and mouth: Not examined.

Neck: no neck pain. No swollen lymph nodes.

Lungs: No wheezing.

Heart: Normal heart sounds as per the clinician. Heart rate and rhythm noted as normal by the clinician.

Abdomen: No nausea or vomiting. No abdominal distension. No abdominal tenderness to tough.

Musculoskeletal: no unusual fatigue. No non-voluntary tremors. No scoliosis. No abnormal gait. No swollen joints. No joint stiffness. Walks, stands, and performs activities of daily living normally.

Extremities: no pitting edema. The extremities noted as normal by the clinician. Radial pulses noted as normal by the examining physician. No ankle swelling.

Skin: Normal pink skin. No pallor or cyanosis. No jaundice. Normally and evenly pigmented skin.

Plan/Management: Adherence to prescribed medications. She has seen a dietician to check on the level of sodium in processed foods that she usually. The dietician has advised her on the type of foods to take and the recommended salt intake. Next follow-up in six-months-time.

This question has been answered

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