SOAP NOTE on Musculoskeletal/Neuro

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 45-year-old white man presents to your office complaining of left knee pain that started last night. He says that the pain started suddenly after dinner and was severe within a span of 3 hours. He denies any trauma, fever, systemic symptoms, or prior similar episodes. He has a history of hypertension for which he takes hydrochlorothiazide (HCTZ). He admits to consuming a great amount of wine last night with dinner .On examination, his temperature is 98°F, his pulse is 90 beats/min, his respirations are 22 breaths/min, and his blood pressure is 129/88 mm Hg. Heart and lung examinations are unremarkable. The patient is reluctant to flex the left knee, wincing in pain at touch, and has passive range of motion. The knee is edematous, hot to touch, and has erythema of the overlying skin. No crepitation or deformity is apparent. No other joints are involved. Inguinal lymph nodes are not enlarged. Complete blood count (CBC) reveals a white blood cell count of 10,900 cells/mm3 and is otherwise normal.

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)

Save Time On Research and Writing

Hire a Pro to Write You a 100% Plagiarism-Free Paper.

Get My Paper

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

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

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)

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

EXP.PROB.
FOCUSED DETAILED -COMPRE

HENSIVE

T
O

R
Y

I
S

*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:

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

– 1 –

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

Est. problem (to examiner); stable, improved 1

Est. problem (to examiner); worsening

New problem (to examiner); no additional
workup planned

Max = 1

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

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

A
L

D
E
C
I
S
I
O

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

ER: EPF
C

ER: D

ER: C Minimal
problem
that may
not
require
presence
of
physician

PF EPF D C

Examination
PF

ER: PF

EPF

ER: EPF

ER: D

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

Turn in your highest-quality paper
Get a qualified writer to help you with

“ SOAP NOTE on Musculoskeletal/Neuro ”

Get high-quality paper

Guarantee! All work is written by expert writers!

Still stressed from student homework?

Get quality assistance from academic writers!

Order now