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Directions: Read over the SOAP note and formulate a primary diagnosis. Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.
- Upload a copy of your completed SOAP note.
- Upload a copy of the evaluation & management score sheet.
Case Study: A 32-year-old woman presents for evaluation of a lump that she noticed in her right breast on self-examination. She says that while she does not perform breast self-examination often, she thinks that this lump is new. She denies nipple discharge or breast pain, although the lump is mildly tender on palpation. She has never noticed any breast masses previously and has never had a mammogram. She has no personal or family history of breast disease. She takes oral contraceptive pills (OCPs) regularly, but no other medications. She does not smoke cigarettes or drink alcohol Links to an external site.. She has never been pregnant. On examination, she is a well-appearing, somewhat anxious, and thin woman. Her vital signs are within normal limits. On breast examination, in the lower outer quadrant of the right breast, there is a 2-cm, firm, well-circumscribed, freely mobile mass without overlying erythema that is mildly tender to palpation. There is no skin dimpling, retraction, or nipple discharge. While no other discrete breast masses are palpable, the bilateral breast tissue is noted to be firm and glandular throughout. There is no evidence of axillary, supraclavicular, or cervical lymphadenopathy. The remainder of her physical examination is unremarkable.
SOAP NOTE GRADING RUBRIC
Guidelines:
1-Use the case study in the description to complete the assignment. Fill in the missing details for each required section that would be expected for the diagnosis.
SUBJECTIVE Analysis (0.2 POINT)
Score received
1-Subjective section should include:
a-Chief complaint (CC)
b-History of present illness (HPI)- All 7 attributes (location, quality, quantity or severity, timing including onset, frequency, and duration, setting in which it occurs, aggravating or relieving factors, and associated symptoms)
c-Past history (Medical, Surgical, Obstetric/Gynecology, Psychiatric)
d-family history (3 generation pedigree of first-degree relatives, i.e. parents, siblings, children)
e. Personal and social history (i.e. sexual history 5p’s)
f. Review of systems (ROS, pertinent positives and/or negatives)
g. Developmentally appropriate-i.e. developmental history if peds, functional assessment and/or dementia screen if elderly
a-Identified and collected the necessary data
b-Categorized and organized data using the appropriate format
c-Incorporated all pertinent data/facts
d- Used proper documentation and proper billing code
e- PATIENT’S CULTURE MUST BE NOTED
OBJECTIVE (0.2POINT)
Score received
1-Objective section should include:
a. General survey
b. Vital Signs (including BMI and growth chart if applicable)
c. All other necessary body systems
d. Diagnostic test if available
a. Identified and collected the necessary data
b. Categorized and organized data using the appropriate format
c.Incorporated all pertinent data/facts
d. Used proper documentation and billing code
ASSESSMENT (0.2 POINT)
Score received
1- Identified correct diagnosis, ICD-10 code, and correct differential diagnosis
a-Filtered relevant data from irrelevant data
b.-Interpreted relationships/patterns among data
(e.g., noted trends)
c.Integrated information to arrive at diagnosis
d.Identified risk factors
d. Used proper documentation
PLAN Analysis (0.2 POINT)
Score received
a-Recommended an appropriate plan for each problem
b-Included recommendations for non-drug and drug therapy
c-Included recommendations for monitoring
d- Included health education
e- Included followup & referrals
f- include cultural considerations of patient care
Incorporate the patient’s culture on the demographic section on SOAP notes.
FORMAT (0.2 POINT)
Score received
1- APA
2- References Current (at least two references, one of which needs to be up to date and the other a clinical practice guideline from a peer reviewed journal article or national organization such as AAFP, ACOG, USPSTF)
3- Writing clear, concise
TOTAL: /1
SOAP FORMAT & RUBRIC
Initials of Patient:
Patient Age:
Patient Ethnicity:
Initials of Provider:
Clinical Setting:
Patient Status: ____New ____Established
SUBJECTIVE DATA; GRADE RECEIVED: _____
Overall Instructions:
1.
Identified and collected the necessary data
2.
Categorized and organized data using the appropriate format
3.
Incorporated all pertinent data/facts
4.
Used proper documentation
5.
LIST at the end of your subjective section the billing level : Problem Focused, Expanded problem focused, detailed, comprehensive (use guidelines for new vs. established patient
6.
Identify cultural influences on care
FORMAT
Chief Complaint:
History of Present Illness:
Location
Quality
Quantity or Severity
Timing (Onset, Duration, Frequency)
Setting
Aggravating and relieving Factors
Associated Symptoms
·
Pertinent Positives and Negatives if it relates to the differential diagnosis of the chief compliant
Past history (include dates):
PMH
·
(Chronic illness (date of onset), hospitalizations (dates), number and gender of sexual partners, risky sexual practices)
·
Medications: Dose, route, frequency
·
Allergies: Medications, Foods, Other Allergens
PSH
·
(Dates, indications, and types of operations)
Past Psychiatric Hx
·
(Illness and timeframe, diagnosis, hospitalizations and treatments)
Obstetrical/Gynecological (obstetric history, menstrual history,
Contraceptive history, and sexual history)
Obstetrical History
·
(Gravida-Para-TPAL)
Menstrual History
·
(Menarche, LMP, PMP, regular/irregular, frequency, duration, quality of flow, Menopause, Post-menopausal bleeding, HRT)
Contraceptive History
·
The types of contraceptive being used, the dates of unprotected sex)
Sexual History
·
(Five P’s: Partners, Practices, Prevention of Pregnancy, Protection from STI’s, and history of STI’s)
Pregnancy and Birth History
·
Maternal health: Gestational or chronic illness (i.e., gestational diabetes, preeclampsia) complications during pregnancy, infections, drugs, alcohol, illicit drug use, and medications.
·
Gestational age at delivery
·
Labor and delivery length: Length of labor, fetal distress, type of delivery (vaginal or cesarean)
·
Neonatal period: Apgar scores, need for intensive care, jaundice, birth injuries, length of stay, birth weight.
Developmental History
·
Age at which milestones were achieved and developmental abilities
·
School- present grade, specific problems, interaction with peers
·
Behavior – enuresis, temper tantrums, thumb sucking, pica, nightmares
Feeding History
·
Breast or bottle fed, types of formula, frequency and amount, reasons for any changes in formula
·
Solids – when introduced, problems created by specific types
·
Fluoride use
Health Promotion/Maintenance
·
Immunizations, Eye exams, dental exams, lead screening, lipid,
Hemoglobin. Colonoscopy, Annual Physical, Mammography,
PAP, Functional Status: ADLs and IADLs
Family History: Alive, Deceased, Age, Diseases, Health Conditions that place patient at risk (ages)
Grandparents
Parents
Siblings
Children
Social History:
Cultural Background
Spiritual History/Religious Affiliation and Practices
Complementary/Alternative Care Practices:
Activities of Daily Living/Hobbies/Interests
Type of Family (Nuclear, Extended etc.)
Occupation of parents
Work History
Financial History
Diet
Exercise
Use of alcohol, smoking, or recreational drugs
Living Arrangements and conditions- school/daycare
Travel History
Social Support
Review of Systems:
Constitutional:
Head/face:
Eyes:
Ears:
Nose:
Mouth/Throat/ Neck:
Respiratory:
Cardiac:
Breast:
GI:
GU:
GYN (female):
Reproductive (Male):
Musculoskeletal:
Skin/Integument:
Psychiatric:
Neuro:
Endocrine:
Hematologic/Lymphatic:
Allergic/Immunologic:
Determine Which LEVEL of HISTORY (Choose one):
Focused HPI (1-3 findings); ROS N.A; PFSH N.A
Expanded HPI (1-3 Findings); ROS 1 or more; PFSH N.A.
Detailed HPI (4 or more findings); ROS 2-9 systems; PFSH one
Comprehensive HPI (4 or more findings or status of 3 or more chronic stable conditions; ROS 10-14; PFSH 2-3 areas
OBJECTIVE DATA; Grade received_____
Overall Instructions:
1.
Identified and collected the necessary data
2.
Categorized and organized data using the appropriate format
3.
Incorporated all pertinent data/facts
4.
Used proper documentation
5.
LIST at the end of your subjective section the billing level : Problem Focused, Expanded problem focused, detailed, comprehensive (use guidelines for new vs. established patient
FORMAT:
Vital Signs:
Oxygen Saturation:
Ht and percentile on growth chart:
Wt and percentile on growth chart:
BMI (if applicable):
Constitutional:
General:
Physical Examination:
Head/face:
Eyes:
Ears:
Nose:
Mouth/Throat/ Neck:
Respiratory:
Cardiac:
Breast:
GI:
GU:
GYN (female):
Reproductive (Male):
Musculoskeletal:
Skin/Integument:
Psychiatric:
Neuro:
Hematologic/Lymphatic/Immunologic:
Determine Billing LEVEL OF PHYSICAL OBJECTIVE EXAM (choose one):
Focused: 1 body area or organ system (1-5 elements);
Expanded problem focused (2-4 body are or organ system (6-11 elements);
Detailed (5-7 see notes);
Comprehensive (8 organ systems see notes);
Laboratory Data Already Ordered and Available for Review (If not done will go in plan):
Diagnostic Procedures/Data Already Ordered and Available for Review (If not done will go in plan):
ASSESSMENT; GRADE RECEIVED____
1)
Main Diagnosis/Problem:
2)
Additional Health Problem/Dx:
3)
Differential Diagnoses for top diagnoses
4)
Identify Risk Factors
PLAN; GRADE RECEIVED________
For Each Diagnosis or Health Problem Identified as Appropriate:
Additional Laboratory Tests or Diagnostic Data Needed
Pharmacologic Management:
Drug, dose, route, frequency, Disp amount
SIG (write like a prescription)
Non-Pharmacologic Management: i.e. hot packs, ice, position changes, TENS unit etc.
Complementary Therapies:
Anticipatory Guidance:
Health Education:
Referrals:
Follow-up Appointment:
For the Encounter Final Level of Decision Making: (give rationale for level which is based on Hx, physical, Decision making); Choose one
Straightforward:
Low Complexity:
Moderate Complexity:
High Complexity:
Billing Level: Give the reason for the Billing by E and M Evaluation Coding as per Number of Systems Reviewed and Level of Physical Exam.
Patient Status: New or established
Level of history
Level of physical (exam)
Level of Medical decision making
For new pick the lowest of the 3 levels
For established: drop the lowest level then pick 2nd lowest level
ANALYSIS
Write 1-2 paragraph summary listing the subjective and objective data that supports your main diagnosis.
Write 1-2 paragraph summary discussing the plan for the main diagnosis.
GENERAL FORMAT REQUIREMENTS:
References:
1.
Analysis must have support from the literature with references within the last 5 years and/or use of clinical evidence-based guidelines. There should be sufficient number of references which are up to date preferably primary sources, research, clinical guidelines etc.
2.
Use of APA style of references in reference list
Writing Style:
1.
Writing should be clear and concise with appropriate use of medical terminology.
2.
Sections identifying subjective data, objective data, assessment, and plan are written in brief short phrases; not full sentences. No need to use the word “patient.”
3.
Demonstrate
your clinical judgment and decision making and the evidence you are using to support your identification of the diagnoses, health problem, or differential diagnoses and management plan.
E/M Documentation Auditor’s Instructions
1. History
Refer to data section (table below) in order to
q
uantify. After referring to data, circle the entry farthest to the RIGHT in the table, which
best describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row to
identify the type of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the type
of history.
After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5.
HPI: Status of chronic conditions:
q 1 condition q 2 conditions q 3 conditions
q
Status of
1-2 chronic
Status of 3
chronic
conditions conditionsOR
HPI (history of present illness) elements:
q Location q Severity q Timing q Modifying factors
q Quality q Duration q Context q Associated signs and symptoms
q
Brief
(1-3)
Extended
(4 or more)
ROS (review of systems):
q Constitutional q Ears,nose, q GI q Integumentaryq Endo
(wt loss, etc) mouth, throat q GU (skin, breast) q Hem/lymph
q Eyes q Card/vasc q Musculo q Neuro q All/immuno
q Resp q Psych q All others negative
q
None
q
Pertinent to
problem
(1 system)
q
Extended
(2-9 systems)
*Complete
PFSH (past medical, family, social history) areas:
q Past history ( the patient’s past experiences with illnesses, operation, injuries and treatments)
q Family history (a review of medical events in the patient’s family, including diseases which may be
hereditary or place the patient at risk)
q Social history (an age appropriate review of past and current activities)
plete ROS: 10 or more systems or the pertinent positives and/or negatives of
q
None
q
Pertinent
(1 history area)
e**Complet
y(2 or 3 histor
areas)
PROBLEM
FOCUSE
D
EXP.PROB.
FOCUSED DETAILED -COMPRE
HENSIVE
q
T
O
R
Y
I
S
H
*Com
some systems with a statement “all others negative”.
**Complete PFSH: 2 history areas: a) Established Patients – Office (Outpatient) Care; b) Emergency Department.
3 history areas: a)
New
Patients – Office (Outpatient) Care, Domiciliary Care, Home Care; b) Initial Hospital Care;
c) Initial Hospital Observation; d) Initial Nursing Facility Care.
NOTE:For certain categories of E/M services that include only an interval history, it is not necessary to record
information about the PFSH. Please refer to procedure code descriptions.
2. Examination
Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination.
Circle the type of examination within the appropriate grid in Section 5.
Limited to affected body area or organ system (one body area or system related to problem) PROBLEM FOCUSED EXAM
Affected body area or organ system and other symptomatic or related organ system(s)
(additional systems up to total of 7)
EXPANDED PROBLEM
FOCUSED EXAM
Extended exam of affected area(s) and other symptomatic or related organ system(s)
(additional systems up to total of 7 or more depth than above) DETAILED EXAM
General multi-system exam (8 or more systems) or complete exam of a single organ system
(complete single exam not defined in these instructions) COMPREHENSIVE EXAM
A
M
E
X
Body areas:
q Head, including face q Chest, including breasts and axillae
q Back, including spine qGenitalia, groin, buttocks
Organ systems:
q
q
Abdomen q Neck
Each extremity
q q q
1 body
area or
system
Up to 7
systems
Up to 7 8 or more
systems systems
q Constitutional q Ears,nose, q Resp q Musculo q Psych
) (e.g., vitals, gen app mouth, throat q GI q Skin
q Eyes q Cardiovascular q GU q Neuro
q Hem/lymph/imm
PROBLEM
FOCUSED
EXP.PROB.
FOCUSED DETAILED COMPRE-
HENSIVE
q
– 1 –
q
q
q
3. Medical Decision Making
Number of Diagnoses or Treatment Options
Identify each problem or treatment option mentioned in the record.
Enter the number in each of the categories in Column B in the table
below. (There are maximum number in two categories.)
Number of Diagnoses or Treatment Options
A B X C = D
Problem(s) Status Number Points Result
Self-limited or minor
(stable, improved or worsening) Max = 2
1
Est. problem (to examiner); stable, improved 1
Est. problem (to examiner); worsening
2
New problem (to examiner); no additional
workup planned
Max = 1
3
New prob. (to examiner); add. workup planned 4
TOTAL
Multiply the number in columns B & C and put the product in column D.
Enter a total for column D.
Bring total to line A in Final Result for Complexity (table below)
Amount and/or Complexity of Data Reviewed
For each category of reviewed data identified, circle the number in the points
column. Total the points.
Amount and/or Complexity of Data Reviewed
Reviewed Data Points
1
1
1
1
1
2
2
Review and/or order of clinical lab tests
Review and/or order of tests in the radiology section of CPT
Review and/or order of tests in the medicine section of CPT
Discussion of test results with performing physician
Decision to obtain old records and/or obtain history from
someone other than patient
Review and summarization of old records and/or obtaining
history from someone other than patient and/or discussion of
case with another health care provider
Independent visualization of image, tracing or specimen itself
(not simply review of report)
TOTAL
Bring total to line C in Final Result for Complexity (table below)
Use the risk table below as a guide to assign risk factors. It is understood that the table below does not
contain all specific instances of medical care; the table is intended to be used as a guide. Circle the
most appropriate factor(s) in each category. The overall measure of risk is the highest level circled.
Enter the level of risk identified in Final Result for Complexity (table below).Risk of Complications and/or Morbidity or Mortality
Level of
Risk
Presenting Problem(s) Diagnostic Procedure(s)
Ordered
Management Options
Selected
Minimal
• One self-limited or minor problem,
e.g., cold, insect bite, tinea corporis
• Laboratory tests requiring venipuncture
• Chest x-rays
• EKG/EEG
• Urinalysis
• Ultrasound, e.g., echo
• KOH prep
• Rest
• Gargles
• Elastic bandages
• Superficial dressings
Low
• Two or more self-limited or minor problems
• One stable chronic illness, e.g., well controlled
hypertension or non-insulin dependent diabetes,
cataract, BPH
• Acute uncomplicated illness or injury, e.g., cystitis, allergic
rhinitis, simple sprain
• Physiologic tests not under stress, e.g.,pulmonary
function tests
• Non-cardiovascular imaging studies with contrast,
e.g., barium enema
• Superficial needle biopsies
• Clincal laboratory tests requiring arterial puncture
• Skin biopsies
• Over-the-counter drugs
• Minor surgery with no identified risk factors
• Physical therapy
• Occupational therapy
• IV fluids without additives
Moderate
• One or more chronic illnesses with mild exacerbation,
progression, or side effects of treatment
• Two or more stable chronic illnesses
• Undiagnosed new problem with uncertain prognosis,
e.g., lump in breast
• Acute illness with systemic symptoms, e.g.,
pyelonephritis, pneumonitis, colitis
• Acute complicated injury, e.g., head injury with brief loss
of consciousness
• Physiologic tests under stress, e.g., cardiac stress test,
fetal contraction stress test
• Diagnostic endoscopies with no identified risk factors
• Deep needle or incisional biopsy
• Cardiovascular imaging studies with contrast and no
identified risk factors, e.g., arteriogram cardiac cath
• Obtain fluid from body cavity, e.g., lumbar puncture,
thoracentesis, culdocentesis
• Minor surgery with identified risk factors
• Elective major surgery (open, percutaneous or
endoscopic) with no identified risk factors
• Prescription drug management
• Therapeutic nuclear medicine
• IV fluids with addititives
• Closed treatment of fracture or dislocation without
manipulation
High
• One or more chronic illnesses with severe exacerbation,
progression, or side effects of treatment
• Acute or chronic illnesses or injuries that may pose a threat to
life or bodily function, e.g., multiple trauma, acute MI,
pulmonary embolus, severe respiratory distress, progressive
severe rheumatoid arthritis, psychiatric illness with potential
threat to self or others, peritonitis, acute renal failure
• An abrupt change in neurologic status, e.g., seizure, TIA,
weakness or sensory loss
• Cardiovascular imaging studies with contrast with
identified risk factors
• Cardiac electrophysiological tests
• Diagnostic endoscopies with identified risk factors
• Discography
• Elective major surgery (open, percutaneous or
endoscopic with identified risk factors)
• Emergency major surgery (open, percutaneous or
endoscopic)
• Parenteral controlled substances
• Drug therapy requiring intensive monitoring for toxicity
• Decision not to resuscitate or to de-escalate care
because of poor prognosis
Final Result for Complexity
Draw a line down any column with 2 or 3 circles to identify the type of decision making in
that column. Otherwise, draw a line down the column with the 2nd circle from the left.
After completing this table, which classifies complexity, circle the type of decision
making within the appropriate grid in Section 5.
Final Result for Complexity
A Number diagnoses or
treatment options
≤ 1
Minimal
2
Limited
3
Multiple
≥ 4
Extensive
B Highest Risk Minimal Low Moderate High
C Amount and complexity
of data
≤ 1
Minimal
or low
2
Limited
3
Multiple
≥ 4
Extensive
Type of decision making STRAIGHT-
FORWARD
LOW
COMPLEX.
MODERATE
COMPLEX.
HIGH
COMPLEX.
4. Time
If the physician documents total time and suggests that counseling or coordinating care dominates
(more than 50%) the encounter, time may determine level of service. Documentation may refer to:
prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk
reduction or discussion with another health care provider.
Face-to-face in outpatient setting
Does documentation reveal total time? Time: Unit/floor in inpatient setting Yes No
Does documentation describe the content of counseling or coordinating care? Yes No
Does documentation reveal that more than half of the time was counseling or
coordinating care? Yes No
If all answers are “yes”, select level based on time.
– 2 –
M
E
D
I
C
A
L
D
E
C
I
S
I
O
N
M
A
K
I
N
G
5. L E V E L O F S E R V I C E
New Office, Outpatient and Emergency Room
New Office / Outpatient / ER Established Office / Outpatient
Requires 3 components within shaded area Requires 2 components within shaded area
History
PF
ER: PF
EPF
ER: EPF
D
ER: EPF
C
ER: D
C
ER: C Minimal
problem
that may
not
require
presence
of
physician
PF EPF D C
Examination
PF
ER: PF
EPF
ER: EPF
D
ER: EPF
C
ER: D
C
ER: C
PF EPF D C
Complexity
of medical
decision
SF
ER: SF
SF
ER: L
L
ER: M
M
ER: M
H
ER: H SF L M H
Average time
(minutes)
ER has no average
time
10 New (99201)
ER (99281)
20 New (99202)
ER (99282)
30 New (99203)
ER (99283)
45 New (99204)
ER (99284)
60 New (99205)
ER (99285)
5
(99211)
10
(99212)
15
(99213)
25
(99214)
40
(99215)
Level I II III IV V I II III IV V
Hospital Care Initial Hospital/Observation Subsequent Hospital/Observation
Requires 3 components within shaded area Requires 2 components within shaded area
History D/C C C PF interval EPF interval D interval
Examination D/C C C PF EPF D
Complexity of medical
decision SF/L M H SF/L M H
Average time (minutes)
30 Init hosp (99221)
30 Init observ Care
(99218)
50 Init hosp (99222)
50 Init observ Care
(99219)
70 Init hosp (99223)
70 Init observ Care
(99220)
15 Sub hosp (99231)
15 Sub observ care
(99224)
25 Sub hosp (99232)
25 Sub observ care
(99225)
35 Sub hosp (99233)
35 Sub observ care
(99226)
Level I II III I II III
Nursing Facility
Care Initial Nursing Facility
Requires 3 components within shaded area
Subsequent Nursing Facility
Requires 2 components within shaded area
Other Nursing Facility
(Annual Assessment)
Requires 3 components within shaded area
History D/C C C PF interval EPF interval D interval C interval D interval
Examination D/C C C PF EPF D C C
Complexity of medical
decision SF/L M H SF L M H L/M
Average time (minutes) 25
99304
35
99305
45
99306
10
99307
15
99308
25
99309
35
99310
30
99318
Level I II III I II III IV
Domiciliary, Rest Home (eg, Boarding Home), or Custodial Care Services and Home Care
Requires 3 components within shaded area Requires 2 onents within shaded area
History PF EPF D C C PF interval EPF interval D interval C interval
Examination PF EPF D C C PF EPF D C
Complexity of
medical decision SF L M M H SF L M M/H
Average time
(minutes)
20
Domiciliary (99324)
Home care (99341)
30
Domiciliary (99325)
Home care (99342)
45
Domiciliary (99326)
Home care (99343)
60
Domiciliary (99327)
Home care (99344)
75
Domiciliary (99328)
Home care (99345)
15
Domiciliary (99334)
Home care (99347)
25
Domiciliary (99335)
Home care (99348)
40
Domiciliary (99336)
Home care (99349)
60
Domiciliary (99337)
Home care (99350)
Level I II III IV V I II III IV
PF = Problem focused EPF = Expanded problem focused D = Detailed C = Comprehensive SF = Straightforward L = Low M = Moderate H = High
– 3 –
Establishe
dcomp
New
- Novitas Solutions Documentation Worksheet
- History Section
- Examination Section
- Medical Decision Making Section
- Time Section
- Level of Service Grids
Soap Note
Florida International University
NGR 6002 – Advanced Health
Assessment
Dr. Rosa Roche & Dr. Dana Sherman
February 1, 2025
Patient Age: 47 years old
Patient Ethnicity: African-American
Clinical Setting: Office visit
Patient Status: Established (since the patient was
seen 3 weeks ago for a follow-up visit)
Subjective Data
Chief Complaint:
“I’m here for a follow-up visit. I was told a few weeks ago that my blood pressure was high, but I
feel fine and don’t have any symptoms.”
History of Present Illness
The patient is a 47-year-old African-American male who presents for follow-up after an
upper respiratory infection visit three weeks ago, where he was incidentally found to have
elevated blood pressure (164/98 mm Hg). He recalls being told in the past that his blood pressure
was ‘borderline’ but has never been formally diagnosed with hypertension. Today, repeat blood
pressure readings are 156/96 mm Hg (left arm) and 152/98 mm Hg (right arm). He denies
headache, dizziness, chest pain, shortness of breath, or other symptoms. His lifestyle includes no
regular exercise and occasional alcohol consumption (“a couple of beers on the weekends”). He
reports no known aggravating or relieving factors. Family history is significant for his father
passing away from a stroke at age 69, increasing his cardiovascular risk.
Past Medical History
Chronic Illness: Hypertension (Date of onset not specified; likely chronic, as patient recalls blood
pressure being “borderline” in the past).
Medications
None.
Past Surgical History
Denies any past surgical history.
Allergies
NKDA
Past Psychiatric History
Denies any past psychiatric history.
Health Promotion and Maintenance
BP check: Elevated blood pressure noted at recent office visits.
Annual Physical: Follow-up visit for blood pressure.
Immunizations: Up to date on routine immunizations, including annual influenza vaccine.
Denies receiving pneumococcal or shingles vaccine.
• Eye exams: Last eye exam was 2 years ago, no corrective lenses needed. Reports occasional
eye strain after prolonged screen time.
• Dental exams: Last visit 9 months ago, no major dental issues, advised to continue routine
care.
• Lipid screening: Last lipid profile performed 18 months ago (results recalled by patient):
• Total Cholesterol: 198
• LDL Cholesterol: 112
• HDL: 49
• Triglycerides: 153
• CBC and BMP: Last completed during a wellness check 1 year ago, within normal limits
(WNL).
• Colonoscopies: Not yet completed. Advised to begin screening at age 50, earlier if family
history changes.
• Annual physical: Last full physical was 15 months ago, noted elevated blood pressure at that
time but no follow-up was done. No prior diabetes screening.
Functional Status:
The patient is fully independent with ADLs.
Family History:
Parents:
• Father: Deceased at age 69 due to stroke.
• Mother: Alive at age 72, in good health.
Siblings:
• Brother (45): No significant health conditions reported.
• Sister (50): Hypertension, obesity (BMI 32).
Social History
Marital status- Divorced
Parental status- Father deceased (stroke at age 69), mother alive (age 72, in good health).
Work history- Works a sedentary job.
Financial history- Stable income, employed full-time in a sedentary job, no major financial
concerns.
Diet- occasional alcohol consumption noted (“a couple of beers on the weekends”).
Exercise- Does not exercise regularly.
Stress management- Reports modest job stress but does not handle it. Lack of formal
stressreduction methods.
Sleep- Reports sleeping 6-7 hours per night, no difficulty falling asleep or staying asleep.
Sexual history/orientation- Heterosexual.
Living arrangement-lives alone in an apartment.
Social support- Limited social support, occasional contact with family, no close friends
mentioned.
Spiritual History/Religious Affiliation and Practices: Identifies as Christian but does not
attend church regularly. Believes in the power of prayer and occasionally engages in personal
reflection for stress relief. Open to discussions about faith in relation to health.
Complementary/Alternative Care Practices: Occasionally takes herbal supplements,
including garlic for heart health. Interested in meditation for stress management but has not yet
implemented it into his routine.
Type of Family: Lives alone but maintains contact with his mother and siblings. Reports having
an extended family network that he reaches out to occasionally for support but is mostly
independent in daily activities.
Travel history- No recent travel history.
Cultural Background
Black and African Americans make up 12.5% of the U.S. population, rising to 15% when
combined with other racial identities (Lang et al., 2022). It is important to acknowledge how
marginalization, discrimination, systemic racism, and access to healthcare disproportionately
affect Black patients compared to White individuals. Implicit bias in clinical decision-making
has been shown to negatively impact patient outcomes, communication, treatment options, and
overall quality of care (Lang et al., 2022).
The current patient, a 47-year-old African American male with newly diagnosed
hypertension, faces several modifiable and non-modifiable risk factors. His family history of
stroke, sedentary lifestyle, and alcohol consumption increase his cardiovascular risk.
Additionally, systemic racism and implicit bias in healthcare settings may contribute to
underdiagnosis and undertreatment of hypertension in Black patients (Lang et al., 2022).
This patient should receive early counseling on lifestyle modifications, including dietary
changes, increased physical activity, and stress management techniques. Providing culturally
competent care that aligns with the patient’s background and traditions is essential for
improving health outcomes. Addressing potential barriers to medication adherence and ensuring
patient education on long-term hypertension management will help improve engagement and
reduce complications (Lang et al., 2022). Encouraging community-based support programs and
fostering trust in healthcare providers can further enhance hypertension control in African
American patients (Lang et al., 2022).
Review of Systems (Patient as Historian)
Constitutional: Denies fever, chills, fatigue, night sweats, or weight changes.
Head/Face: Denies headaches, facial pain, trauma, or swelling.
Eyes: Denies vision changes, redness, dryness, irritation, discharge, or eye pain.
Ears: Denies hearing loss, tinnitus, vertigo, ear pain, or discharge.
Nose: Denies nasal congestion, rhinorrhea, epistaxis, or sinus pain.
Mouth/Throat/Neck: Denies sore throat, dysphagia, hoarseness, oral ulcers, neck swelling, or
pain.
Respiratory: Denies cough, dyspnea, wheezing, or hemoptysis.
Cardiac: Denies chest pain, palpitations, orthopnea, or edema.
Gastrointestinal (GI): Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or blood
in stool.
Genitourinary (GU): Denies dysuria, frequency, urgency, hematuria, or flank pain.
Reproductive (Male): Denies penile discharge, erectile dysfunction, or testicular pain/swelling.
Musculoskeletal: Denies joint pain, stiffness, swelling, or muscle weakness.
Skin/Integumentary: Denies rashes, itching, lesions, or changes in skin color/texture.
Psychiatric: Denies anxiety, depression, mood changes, or insomnia.
Neurological: Denies headaches, dizziness, seizures, numbness, or weakness. No Kernig’s or
Brudzinski’s signs.
Endocrine: Denies polyuria, polydipsia, heat/cold intolerance, or hair/skin changes.
Hematologic/Lymphatic: Denies easy bruising, bleeding, or lymph node enlargement.
Allergic/Immunologic: Denies allergies, recurrent infections, or autoimmune symptoms
Level of History:
Comprehensive
• HPI: 4 or more findings documented.
• ROS: Covers 10-14 systems (meeting “Comprehensive” level).
• PFSH: Includes 2-3 areas (Past Medical, Family, and Social History).
11810000000015187
11810000000015187
11810000000015187
PE
Objective Data
Vital Signs:
• Blood Pressure: 156/96 mm Hg (left arm), 152/98 mm Hg (right arm)
• Heart Rate: 78 bpm
• Respiratory Rate: 14 breaths/min
• Oxygen Saturation: 98% on room air
• Temperature: Afebrile (assumed normal)
• Height: 70 inches (5’10”)
• Weight: 210 lbs
• BMI: 30.1 (obese per CDC guidelines)
Constitutional: Well-groomed, appears stated age, no distress. No jaundice, cyanosis, or pallor.
General: No acute distress, well-nourished, well-developed.
Physical Examination
Head/Face: Normocephalic, atraumatic, symmetrical facial movements. No swelling or
tenderness.
Eyes: PERRLA, EOMI. Conjunctiva clear, sclera white, no discharge.
Ears: Normal external ears, no lesions or discharge. TM intact bilaterally.
Nose: Midline, no septal deviation. Nasal mucosa pink, no discharge or polyps.
Mouth/Throat/Neck: Moist oral mucosa, no ulcers. Tonsils not enlarged. No thyromegaly or
lymphadenopathy.
Respiratory: Symmetric chest expansion, clear bilateral breath sounds. No wheezes, rhonchi, or
rales.
Cardiac: Regular rate and rhythm (RRR). S1, S2 present, no murmurs, rubs, or gallops. No
heaves or thrills. Capillary refill <2 sec.
GI: Soft, non-tender, non-distended. Normal bowel sounds, no hepatosplenomegaly.
GU: No lesions, normal external genitalia. No inguinal hernias.
Reproductive (male): No penile lesions, discharge, or testicular masses. No tenderness or
swelling of the testes or epididymis. No inguinal or femoral hernias noted.
Musculoskeletal: Full range of motion in all extremities, no joint tenderness or swelling. Normal
gait.
Skin: Warm, dry, intact, no lesions or ulcers. Normal turgor.
Neurological: CN II-XII grossly intact. 5/5 strength bilaterally. Normal coordination, sensation
intact to light touch. No Kernig’s or Brudzinski’s signs.
Psychiatric: Calm, cooperative, appropriate mood and affect. No signs of acute distress.
Hematologic/Lymphatic/Immunologic: No lymphadenopathy, bruising, or signs of immunologic
dysfunction.
Billing Level of Physical Objective Exam:
• Comprehensive
• 8 or more organ systems examined (meeting the highest level of physical exam
documentation).
Laboratory Data Already Ordered and Available for Review:
• No labs reviewed during this visit; labs will be ordered in the plan section.
Diagnostic Procedures/Data Already Ordered and Available for Review:
• No imaging or diagnostic tests reviewed during this visit; necessary tests will be included
in the plan section.
Assessment
Main Diagnosis/Problem:
Primary Diagnosis: Hypertension (Essential, Primary)
ICD-10 Code: I10 – Essential (Primary) Hypertension (WHO, 2022)
Differential Diagnosis:
Secondary Hypertension (due to kidney disease, endocrine disorders) (Hegde & Aeddula, 2023)
White Coat Hypertension (office readings elevated, but normal at home) (Townsend & Cohen,
2024)
Obstructive Sleep Apnea (due to weight, sedentary lifestyle) (Slowik & Collen, 2024)
Rationale for Main Diagnosis:
The patient has consistently elevated blood pressure readings (164/98 mm Hg and 156/96 mm
Hg). He has no symptoms but is at increased risk due to family history (stroke in father) and lack
of regular exercise. His blood pressure has been borderline in the past, suggesting a possible
history of untreated or poorly managed hypertension (WHO, 2022).
Risk Factors:
Family history of stroke (father at age 69)
Age (47 years old)
Obesity (BMI of 32.3)
Sedentary lifestyle
Alcohol use (occasional beer consumption).
This visit involves the evaluation and management of an established patient with a chronic
condition (hypertension). The comprehensive history, detailed physical exam, and moderate
complexity decision-making support the use of E/M code 99214, per standard billing guidelines.
Plan
Hypertension (Primary)
Additional Laboratory Tests or Diagnostic Data Needed:
• Basic metabolic panel (BMP) to assess kidney function
• Lipid profile to evaluate cardiovascular risk
• Urinalysis to rule out secondary causes (e.g., kidney disease)
• EKG to assess for signs of cardiac strain
Pharmacologic Management:
• Drug: Lisinopril 10 mg, oral, once daily
• SIG: Take 1 tablet by mouth once a day
• Dispense amount: 30 tablets (1 month supply)
Non-Pharmacologic Management:
• Encourage weight loss (aim for 5-10% reduction in body weight)
• Increase physical activity (at least 150 minutes of moderate-intensity exercise per week)
• Limit alcohol consumption to 1-2 drinks per day
Complementary Therapies:
Consider adding relaxation techniques (e.g., yoga, meditation) to manage stress
Health Education:
• Educate patient on the importance of controlling blood pressure to prevent complications
such as stroke and heart disease
• Discuss the role of lifestyle modifications (diet, exercise, alcohol intake) in managing
hypertension
Referrals:
Referral to dietitian for weight management and nutritional counseling
Follow-up Appointment:
Recheck blood pressure in 2 weeks to assess initial response to medication. Follow-up in 1
month to evaluate medication adherence, potential side effects, and treatment effectiveness. The
patient will be instructed on how to properly measure and record home blood pressure readings,
which will be reviewed at each follow-up to guide therapy adjustments as needed.
Patient Status: Established
Level of History: Comprehensive (HPI includes 4+ elements, ROS covers 10+ systems, PFSH
includes 2+ areas)
Level of Physical Exam: Detailed (5-7 organ systems) or Comprehensive (8+ organ systems)
Level of Medical Decision-Making: Moderate Complexity (chronic condition requiring
medication and diagnostic testing)
Billing Code: 99214 (Established patient, moderate complexity, detailed exam)
Justification: The patient presents for follow-up on persistently elevated blood pressure readings
with a history of “borderline” hypertension. This visit includes a comprehensive history, a
detailed physical examination covering multiple systems, and moderate medical decisionmaking,
including initiation of pharmacologic therapy and lifestyle modifications.
Analysis
Hypertension is a major risk factor for cardiovascular morbidity and mortality,
particularly among African American men, who are disproportionately affected by the condition
(WHO, 2022). This patient’s persistently elevated blood pressure readings (164/98 mm Hg at the
previous visit and 152/98 mm Hg currently) place him at high risk for complications such as
stroke, myocardial infarction, and kidney disease. Despite a slight reduction in his blood
pressure, his levels remain above the hypertension threshold (≥140/90 mm Hg), necessitating
immediate intervention. His father’s history of stroke at age 69 further increases his
cardiovascular risk. Given the patient’s lack of symptoms, sedentary lifestyle, and occasional
alcohol consumption, pharmacologic and lifestyle modifications are essential for effective
hypertension management (WHO, 2022).
Pharmacologic and Non-Pharmacologic Management
The first-line pharmacologic treatment for this patient is Lisinopril 10 mg, oral, once
daily, an angiotensin-converting enzyme (ACE) inhibitor. ACE inhibitors have shown efficacy in
reducing blood pressure and providing renal protection, particularly in patients with
cardiovascular risk factors (Hegde & Aeddula, 2023). However, studies indicate that African
American patients may respond better to calcium channel blockers (CCBs) or thiazide diuretics
than ACE inhibitors (WHO, 2022). If Lisinopril alone does not provide adequate control,
Amlodipine (a CCB) or Hydrochlorothiazide (a thiazide diuretic) may be considered as
alternative or adjunctive therapy
(Townsend & Cohen, 2024).
Non-pharmacologic interventions are equally essential for blood pressure control. The
DASH diet (Dietary Approaches to Stop Hypertension), which emphasizes reducing sodium
intake (<2,300 mg/day) and increasing potassium-rich foods, has been shown to lower blood
pressure significantly (WHO, 2022). Weight loss of 5-10% of total body weight, at least 150
minutes of moderate-intensity exercise per week, and limiting alcohol intake to ≤2 drinks per day
are strongly recommended. The patient should also be encouraged to self-monitor his blood
pressure at home and maintain a blood pressure log for review at follow-up visits (Hegde &
Aeddula, 2023).
Monitoring and Follow-Up
Close monitoring is crucial to ensure effective hypertension management and prevent
complications. The patient should have blood pressure checks every two weeks initially to assess
medication response and adherence. Additional laboratory tests, including a basic metabolic
panel (BMP), lipid panel, HbA1c, and urinalysis, should be conducted to evaluate kidney
function, lipid abnormalities, and potential secondary causes of hypertension (Hegde & Aeddula,
2023). If his blood pressure remains uncontrolled at the next follow-up visit, treatment
intensification with dose adjustments or additional antihypertensive agents will be considered
(Townsend & Cohen, 2024).
Patient Education
Since hypertension is often asymptomatic, patient education is critical to improving
adherence. The patient should be informed about the long-term consequences of uncontrolled
hypertension, including stroke, heart failure, and kidney damage (WHO, 2022). He should
receive guidance on reading nutrition labels, reducing processed foods, and incorporating
healthier meal options to improve his dietary habits. Additionally, stress management techniques,
such as yoga, deep breathing exercises, or mindfulness practices, may be beneficial in lowering
blood pressure (Slowik & Collen, 2024). Encouraging the patient to participate in community
health programs or hypertension support groups may enhance motivation and adherence to
treatment.
Referrals and Cultural Considerations
The patient should be referred to a dietitian for weight management and nutritional
counseling and a primary care physician for continued hypertension
management.
Given his
African American background, it is essential to address cultural barriers to healthcare access and
medication adherence (Townsend & Cohen, 2024). Research indicates that African Americans
have higher rates of treatment-resistant hypertension due to genetic predisposition,
socioeconomic disparities, and healthcare access challenges (Slowik & Collen, 2024).
Establishing trust, providing culturally tailored education, and ensuring accessible care options
will significantly improve adherence and health outcomes.
Conclusion
A comprehensive approach combining pharmacologic therapy, lifestyle modifications,
frequent monitoring, and culturally competent patient education will help optimize this patient’s
blood pressure control and reduce his risk of future cardiovascular events. A four-week followup
visit is scheduled to reassess blood pressure trends, medication adherence, and laboratory results.
If necessary, medication adjustments will be made to ensure long-term hypertension
management.
References
Hegde, S., & Aeddula, N. R. (2023). Secondary Hypertension. Nih.gov; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK544305/
Lang, Q., Roberson-Moore, T., Rogers, K. M., & Wilson, W. E. (2022). Cultural considerations
in working with Black and African American youth. Child and Adolescent Psychiatric
Clinics of North America, 31(4), 733–744. https://doi.org/10.1016/j.chc.2022.05.003
Slowik, J. M., & Collen, J. F. (2024). Obstructive sleep apnea. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK459252/
Townsend, R. R., & Cohen, J. B. (2024). White coat hypertension & cardiovascular outcomes.
Current Hypertension Reports. https://doi.org/10.1007/s11906-024-01309-0
WHO. (2022). Hypertension. Www.who.int. https://www.who.int/health-topics/hypertension
https://www.ncbi.nlm.nih.gov/books/NBK544305/
