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Focused SOAP Note Sample

8/30/22, 12:49 PM Print Preview
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Current Medications
Taking
Donepezil HCl 10 MG Tablet 1 tablet
at bedtime Orally Once a day
Meloxicam 7.5 MG Tablet 1 tablet
Orally Once a day
Losartan Potassium 50 MG Tablet 1
tablet Orally Once a day
Ibandronate Sodium 150 MG Tablet 1
tablet Orally Once a month
Medication List reviewed and reconciled
with the patient
Past Medical History
Essential (primary) hypertension.
Dementia in other diseases classified
elsewhere with behavioral disturbance.
Other polyosteoarthritis.
Bed confinement status.
Dependence on wheelchair.
Obesity (BMI 30.0-34.9).
Osteoporosis without current
pathological fracture, unspecified
osteoporosis type.
Surgical History
Denies Past Surgical History
Family History
Father: deceased
Mother: deceased
Social History
Tobacco Use:
Tobacco Use/Smoking
Tobacco use: nonsmoker
Allergies
N.K.D.A.
Hospitalization/Major
Diagnostic Procedure
Denies Past Hospitalization
Review of Systems
Reason for Appointment
1. Initial evaluation
History of Present Illness
Examination:
70-year-old female with a past medical history significant for
dementia, bed/wheelchair confinement, hypertension, osteoarthritis,
osteoporsis and obesity was seen for an initial examination (telehealth) to
discuss her chronic medical conditions, evaluate for medical services, and
discuss remote patient monitoring. Limited subjective assessment due to
chronic diagnosis of dementia, medical concerns addressed by daughter.
The patients daughter states that she eats a relatively healthy diet and is
minimally physically active throughout the day however does require an
assistive device to ambulate (wheelchair). She complains of occasional
bilateral knee pains; however, she states that she is cautious when
ambulating and has not fallen recently. She currently is under the care of
primary care physician unsure of name also has a caretaker seven days a
week for several hours (approximately 7 hours each day). Her caretaker
helps her get dressed, take care of light housekeeping, assist with general
hygiene, prepare food and occasionally go out for short walks. The patients
caretaker states she is taking and tolerating all of her medications as
prescribed without any adverse effects. Daughter denies any chest pains,
palpitations, shortness of breath, abdominal pain, nausea, vomiting,
diarrhea, constipation, fevers, chills, night sweats, dizziness, acute visual
abnormalities, headaches, syncopal episodes, recent known infections,
recent antibiotic use, or any other acute complaints or abnormalities.
Vital Signs
Wt 190 lbs, Wt-kg 86.18 kg, Ht 65 in, Ht-cm 165.1 cm, BMI 31.61 Index,
Body Surface Area 1.99.
Examination
General Examination:
TeleHealth Visit.
Physical Examination
Refer to examination.
Assessments
1. Essential hypertension – I10 (Primary)
2. Primary osteoarthritis involving multiple joints – M89.49
DARIUS, YVESROSE DOB: 05/08/1951 (70 yo F) Acc No. 24515 DOS: 12/30/2021
DARIUS, YVESROSE
70 Y old Female, DOB: 05/08/1951
Account Number: 24515
750 OCEAN AVE, APT 1C, BROOKLYN, NY-11226-5308
Home: 718-282-4651
Guarantor: DARIUS, YVESROSE Insurance: Medicare of New
York Payer ID: NYMRE
Appointment Facility: telehealth
12/30/2021 Progress Notes: Gina M Marotto, PA-C, MPAS
Progress Note: Gina M Marotto, PA-C, MPAS 12/30/2021
Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com)
8/30/22, 12:49 PM Print Preview
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GENERAL/CONSTITUTIONAL:
Patient denies change in appetite
, chills , fatigue , fever , headache ,
lightheadedness , night sweats ,
sleep disturbance , weight gain ,
weight loss , weakness.
RESPIRATORY:
Patient denies cough , shortness
of breath.
CARDIOVASCULAR:
Patient denies chest pain ,
dizziness , palpitations , shortness
of breath , weakness.
Comments Essential Hypertension.
MUSCULOSKELETAL:
Patient denies history of gout ,
swollen joints, trauma. Patient
complains of arthritis / arthralgia,
joint stiffness and pain , painful
joints , weakness.
NEUROLOGIC:
Patient denies dizziness ,
fainting. Patient complains of loss of
strength , memory loss.
3. Gait abnormality – R26.9
4. Counseling and coordination of care – Z71.89
5. Dementia in other diseases classified elsewhere with behavioral
disturbance – F02.81
6. Dependence on wheelchair – Z99.3
7. Obesity (BMI 30.0-34.9) – E66.9
Treatment
1. Essential hypertension
Notes: I reminded the caregiver of the importance of following a
DASH diet and monitoring their sodium intake (below 2-3 g per
day). The DASH diet consists of fruits, vegetables, whole grains, poultry,
and fish while limiting sugars, red meat, and alcohol. In addition, I
encouraged the caregiver to monitor blood pressure at least
once per day. Continue current medication(s) as prescribed. Discussed
risks and complications of non compliance with medical recommendations
including but not limited to myocardial infarction, cerebrovascular
accident and death.
2. Primary osteoarthritis involving multiple joints
Notes: The patient’s complaints are consistent with osteoarthritis, a
breakdown of cartilage from the joints causing the bone to grind on bone. I
explained to the patient that osteoarthritis usually attacks large
joints; however, it can also affect smaller joints such as the
hand. In addition, painful bone spurs are common with osteoarthritis.
Risk factors include age, obesity, female sex, a previous joint injury, and a
family history of arthritis.Continue current medication as prescribed.
3. Counseling and coordination of care
Notes: I had an extensive conversation with the patients
caretaker, completing the necessary criteria to bill for CCM /
RPM services. After completing an assessment and CCM care planning, I
initiated CCM services, meeting the comprehensive assessment and care
planning requirements. I discussed the availability of CCM services in
applicable call sharing. I made it clear that only one practitioner could
furnish and be paid for CCM services during a calendar month. The patient
has the right to stop CCM services at any time. Lastly, I offered remote
patient monitoring services, which I explained would help us
manage the patient remotely. Our care managers will report any
abnormalities within a reasonable amount of time. Based on the patient’s
values, I will discuss if further intervention is needed. CCM goals and
expected outcomes: 1) Tight glycemic control with a hemoglobin A1c less
than 6.5 (American Diabetes Association), 2) Blood pressure control with a
target reading below 130/80 (American Heart Association), 3) Vitamin D
level greater than 30, 4) LDL below 70, triglycerides below 150, 5) Weight
reduction, 6) Remaining up to date with immunizations including flu,
pneumococcal, Tdap, shingles, COVID-19, and Hepatitis. The patient’s
chronic conditions are stable, and with continued monitoring
and encouragement, the goals set forth are achievable
A) The patient requires frequent reminders and reinforcements
to achieve the goals we set forth, hopefully optimizing their
general health as best as possible. B) I discussed the care plan with
the patient’s nurse, aide, and other providers. C) I advised that we
regularly monitor the patient’s blood pressures and establish a trend to
DARIUS, YVESROSE DOB: 05/08/1951 (70 yo F) Acc No. 24515 DOS: 12/30/2021
Progress Note: Gina M Marotto, PA-C, MPAS 12/30/2021
Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com)
8/30/22, 12:49 PM Print Preview
3/4
ascertain efficacy and stability. D) Routine lab work. E) Continued
encouragement, nutritional counseling, and adherence to lifestyle
modifications, mainly targeting obesity. F) I hope that the patients
caretaker will continue to follow the above recommendations.
However, the prognosis is dependent on the patient’s
intervention and cooperation with the above guidelines.
4. Dementia in other diseases classified elsewhere with
behavioral disturbance
Clinical Notes: Reiterated importance of medication compliance, routine
follow up with neurology, implementation of reorientation exercises and
verbal communication to slow progression and exacerbation of symptoms.
Discussed risks and complications of non compliance with medical
recommendations including but not limited to failure to thrive and death.
5. Dependence on wheelchair
Clinical Notes: Hospital bed requested, prescribed. Reiterated importance
of repositioning and implementation of supportive medical equipment
including but not limited to wheelchair cushion and hospital bed to
decrease risk of skin breakdown/skin ulcerations. Fall risk assessment
completed, patient is a high fall risk. Reiterated importance of ambulating
with assistive device for support and to decrease risk of falls. Discussed
risks and complications of non compliance with medical recommendations
including but not limited to fracture, hemorrhage, deep venous
thrombosis, respiratory failure, osteomyelitis, sepsis and death.
6. Obesity (BMI 30.0-34.9)
Clinical Notes: Reiterated importance of continued implementation of diet
modification. Avoid foods with high fat content to decrease risk of
potential complications and risks including but not limited to myocardial
infarction, cerebrovascular accident and death.
Procedure Codes
G0447 FCE-FCE BEHAVRL CNSL OBESITY 15 MIN
99443 PHONE E/M BY PHYS 21-30 MIN
G8427 DOC MEDS VERIFIED W/PT OR RE
0518F FALL PLAN OF CARE DOCD
3288F FALL RISK ASSESSMENT DOCD
G8938 BMI CALC BUT PT NOT ELIG F/U PLAN
Follow Up
2 Weeks (Reason: wheelchair dependence)
Electronically signed by Gina Marotto , PA-C,MPAS on
12/30/2021 at 03:37 PM EST
Sign off status: Completed
DARIUS, YVESROSE DOB: 05/08/1951 (70 yo F) Acc No. 24515 DOS: 12/30/2021
Progress Note: Gina M Marotto, PA-C, MPAS 12/30/2021
Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com)
8/30/22, 12:49 PM Print Preview
4/4
telehealth
1573 E 22ND ST
BROOKLYN, NY 11210-5109
Tel: 646-919-0757
Fax:
DARIUS, YVESROSE DOB: 05/08/1951 (70 yo F) Acc No. 24515 DOS: 12/30/2021
Progress Note: Gina M Marotto, PA-C, MPAS 12/30/2021
Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com)

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