documentation challenge

[umbo.livejournal.com]

This thing hit me this morning--woke up to pee, couldn't get back to sleep until I wrote it. Beta thanks to ckr and ardent_muses.



Note: SOAP is how health care providers are trained to organize their notes for a patient/client. S stands for Subjective, or the things the client tells you, like their complaints and their medical history. O stands for Objective, or the actual physical findings of the exam. A stands for Assessment, which is the conclusion you draw (e.g. this client may have diabetes), and P stands for Plan, or what you're going to do about it (e.g. send them for a glucose tolerance test). WNL stands for "within normal limits," HTN is hypertension, and DM is diabetes. Not that knowing any of that is really important ;-)

SOAP Note

Pt's Name: Ray Kowalski MR# 966534
7/12/03 4:30 pm

S: 43 yo WM presents for annual physical. Denies probs/questions.
Med. Hist.: Usual childhood diseases. + frostbite L great toe 1998, no amputation. + broken arm age 8; broken nose age 20; gunshot to abdomen, 1989; dogsled accident 2000 (stitches R leg, no broken bones).
Surg: Abdominal (remove bullet) 1989, no complications, no probs. with anesthesia.
Hosp: 1989, see above.
Fam. Hist.: + HTN (F, PGF, PGM), + prostate cancer (MGF), + breast cancer (MGM), + DM (PGM), + osteoarthritis (PGF, PGM, MGM).
Social Hist.: Imm. from US in 1998 to be with current partner, who is RCMP officer. Works in snowmobile repair and "odd jobs." Former police officer. Ed: 14 years. Divorced; going to Toronto in 2 wks to marry current (m) partner.
Sex. Hist: Bisexual; has been with current partner x 5 yrs. Uses condoms. States he and partner have both been tested and are HIV negative.
Denies phys/sex abuse.
Allergies: NKMA; environmental (cats).
Exercise: dogsledding, snowshoeing, walking.
Denies smoking/drugs, states occ. beer.
Meds: Occ. ibuprofen or tylenol; states occ. uses salve made by partner for sore muscles/joints.
24 hour diet recall: coffee with smarties, cereal with milk, pizza. States eats better when partner is not on patrol.

O: BP 126/74, P 85, T 97.9 oral, RR 16
Ht: 5'11 Wt: 160 BMI 22
Gen'l: Pleasant, thin, no apparent distress.
HEENT: Wears glasses, otherwise WNL, no thyromegaly, no lympadenopathy. Teeth in good repair.
Heart: RRR; S1, S2; no murmur.
Lungs: Clear to auscultation, resp. easy & unlabored.
Neuro: Grossly intact; reflexes +3 bilat.
Skin: Pink, warm; scar L great toe, R thigh, lower R abdomen. No varicosities. Tattoos R shoulder, L hip.
Abd: NT, no organomegaly. Surgical/gunshot scar well approximated, no keloids.
Back: No scoliosis, - CVAT.
Extremities: Normal ROM; - Homan's; + crepitus bilat. knees. No clubbing of fingers, capillary refill <3 sec.
Genitalia: Normal male, testes non-enlarged, symm., no masses, no hydrocele.
Rectal: prostate NT, non-enlarged; guaiac -.

A/P: Phys. exam WNL except mild arthritis both knees.
Advised cont. weight bearing exercise, good diet, incr. protein and calcium intake, importance of incr. intake in this climate. Given info on testicular self-exam, revised food pyramid. Advised biannual PSA due to family history of prostate cancer.
Labs: PSA, CBC, lipid profile.
RTC 1 year and prn.

--C. Maclean, NP, MS

Comments

[shayheyred.livejournal.com]

Verrrrry interesting.

Does anyone else want to know what the tattoo on his left hip is???

(Hey - I just shot the guy in his leg; you shot him in the stomach. Meanie.)

[umbo.livejournal.com]

Does anyone else want to know what the tattoo on his left hip is???

Hee. Ardent asked, too. I didn't tell her either ;-).

[ardent-muses.livejournal.com]

Personally, I think "hip" is a euphemism. *G*

He's got a maple leaf on his ass.

Loved this.

[umbo.livejournal.com]

Hee! You nailed it, m'dear! You know me so well ;-)