Soap Note Acute Frontal Sinusitis

Semester:

Spring

Course:

MSN6150C Advanced Practice Pediatrics

Preceptor:

REYES-CHOUZA, CARLOS

Clinical Site:

IDEAL MEDICAL CENTER

Setting Type:

Patient Demographics

Age:

12 years

Race:

Black or African American

Gender:

Male

Insurance:

Medicaid

Referral:

No referral

Clinical Information

Time with Patient:

25 minutes

Consult with Preceptor:

15 minutes

Type of Decision-Making:

Moderate complexity

Reason for Visit:

New Consult

Chief Complaint:

Felling pressure behaving my eyes

Type of HP:

Detailed

Social Problems Addressed:

Sanitation/Hygiene Emotional Prevention

Procedures/Skills (Observed/Assisted/Performed)

Physical Assessment – Physical Assessment (Perf) General Skills – Vital Signs (Perf)

ICD-10 Diagnosis Codes

#1 –

J01.10 – ACUTE FRONTAL SINUSITIS, UNSPECIFIED

CPT Billing Codes

#1 –

99214 – OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; MODERATE LEVEL MED DECISION; 30-39 MIN

Birth & Delivery

Medications

# OTC Drugs taken regularly:

0

# Prescriptions currently prescribed:

0

# New/Refilled Prescriptions This Visit:

2

Types of New/Refilled Prescriptions This Visit: Analgesic/Antipyretic – NSAIDS Infectious Diseases – Penicillins

Adherence Issues with Medications: Knowledge deficit

Other Questions About This Case

Patient’s Primary Language:

English

Smoking Assessment:

Never

Advanced Directive:

No

Packs per day:
(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C

Soap Note # ____ Main Diagnosis ______________

PATIENT INFORMATION

Name:

Age:

Gender at Birth:

Gender Identity:

Source:

Allergies:

Current Medications:

·

PMH:

Immunizations:

Preventive Care:

Surgical History:

Family History:

Social History:

Sexual Orientation:

Nutrition History:

Subjective Data:

Chief Complaint:

Symptom analysis/HPI:

The patient is …

Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL:

SKIN:

Objective Data:

VITAL SIGNS:

GENERAL APPREARANCE:

NEUROLOGIC:

HEENT:

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:

ASSESSMENT:

(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)

Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)

Main Diagnosis

(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.

Differential diagnosis (minimum 3)

–

–

–

PLAN:

Labs and Diagnostic Test to be ordered (if applicable)

· –

· –

Pharmacological treatment:

–

Non-Pharmacologic treatment:

Education (provide the most relevant ones tailored to your patient)

Follow-ups/Referrals

References (in APA Style)

Examples

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).

ISBN 978-0-8261-3424-0

Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010

(25th ed.). Print (The 5-Minute Consult Series).