In this course project assignment, you are presented with clinical notes for two different patients. These progress notes have been recorded as SOAP notes. A SOAP note is a common method of documenting a patient’s visit with a healthcare provider. These notes are saved in a patient’s medical record and will be used for treatment, billing, and other activities to monitor the patient’s health over time.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. Each of these components is used to record a vital part of the patient’s visit.
- Subjective: Includes the patient’s complaints and states the patient’s symptoms in his or her own words
- Objective: Includes information that the provider can measure, such as vital signs, weight, or findings from a physical exam
- Assessment: Includes a differential diagnosis or summary of signs and symptoms
- Plan: Includes treatments performed, follow-up appointment information, referrals, or other orders
You will be exploring the medical terminology used in these SOAP notes and will be asked to interpret the meanings of various words and abbreviations.
To complete this assignment, do the following:
- Download the clinical notes for the two patients:
Kay Salisbury Clinical Notes (I have attached it below)
Virginia Thompson Clinical Notes (I have attached it below)
- Download, complete, and submit the document below. This document contains questions you will answer regarding the clinical notes for each patient.
Module 02 Course Project Assignment Template (I have attached it below)
PLEASE USE A BLANK WORD DOCUMENT TO ANSWER THE QUESTIONS ON THE COURSE PROJECT QUESTIONS DOCUMENT
Chief complaint
Low back pain
PATIENT
Kay Salisbury
DOB 03/30/1983
AGE
34 yrs
SEX Female
PRN DP278077
FACILITY
Northstar Physicians Center
T (999) 999-9999
1234 Sunshine Way
100
Minneapolis, MN 99999
ENCOUNTER
NOTE TYPE SOAP Note
SEEN BY Nazir Ashaad
DATE 04/05/2017
AGE AT
DOS
34 yrs
Not signed
Patient identifying details and demographics
FIRST NAME Kay
MIDDLE NAME
–
LAST NAME Salisbury
SSN –
SEX Female
DATE OF BIRTH 03/30/1983
DATE OF DEATH –
PRN DP278077
ETHNICITY –
PREF.
LANGUAGE
–
RACE White
STATUS Active patient
CONTACT INFORMATION
ADDRESS LINE 1 4994 Shady
Range
ADDRESS LINE 2 –
CITY Ossawinamakee
Beach
STATE MS
ZIP CODE 39469
CONTACT BY –
EMAIL –
HOME PHONE (555) 555-5555
MOBILE PHONE (555) 555-5555
OFFICE PHONE –
OFFICE
EXTENSION
–
FAMILY INFORMATION
NEXT OF KIN –
RELATION TO PATIENT –
PHONE –
ADDRESS –
PATIENT’S MOTHER’S
MAIDEN NAME
–
PATIENT NOTES
Prefers that major diagnoses be discussed with her cardiologist Dr. Seifert
Subjective
The patient is a 34-year-old woman who presents with complaints of back pain. She describes the pain as a “dull ache in
my lower back and into my right hip.” She is unable to identify any reason for the onset of pain. The pain does not
radiate down legs. The patient states that the pain has been present for 2 weeks and is progressively getting worse. No
urinary or fecal incontinence. Patient has not had any imaging studies.
She states that sometimes the pain is worst in the morning and other times it bothers her more during the day. OTC
anti-inflammatory medication and ice have provided temporary relief.
Objective
Encounter – Office Visit Date of service: 04/05/17 Patient: Kay S… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
1 of 2 4/5/17, 4:31 PM
Patient’s blood pressure is 116/78.
Patient’s HR is 80 bpm and regular.
Pain is rated 5/10 while resting and 7/10 while standing and walking.
Lumbar spine ROM is limited to 50 degrees of flexion. All other lumbar ROM tests are WNL.
Physical exam indicates bilateral lumbar muscle spasm and hypertrophy.
Assessment
DDX: Lumbar strain with radiculopathy into the right hip and posterior thigh. Possible unilateral vertebral disk herniation
or DJD of lumbar spine.
Lumbar strain [847.2]. Lumbar pain [724.2].
Plan
Patient is encouraged to continue OTC anti-inflammatory medication b.i.d. Patient will be referred for lumbar and
sacroiliac radiography. Radiographic findings will determine the need for follow-up MRI or physical therapy referral. The
patient was given a handout on gentle low back stretches and was encouraged to try several gentle yoga positions at
home.The patient should return to the clinic in one week.
Free cloud based EHR
Encounter – Office Visit Date of service: 04/05/17 Patient: Kay S… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
2 of 2 4/5/17, 4:31 PM
Chief complaint
Skin lesion
PATIENT
Virginia T Thompson
DOB 02/05/1957
AGE
60 yrs
SEX Female
PRN MO686770
FACILITY
Northstar Physicians Center
T (999) 999-9999
1234 Sunshine Way
100
Minneapolis, MN 99999
ENCOUNTER
NOTE TYPE SOAP Note
SEEN BY Nazir Ashaad
DATE 04/05/2017
AGE AT
DOS
60 yrs
Not signed
Patient identifying details and demographics
FIRST NAME Virginia
MIDDLE NAME T
LAST NAME Thompson
SSN
–
SEX Female
DATE OF BIRTH 02/05/1957
DATE OF DEATH –
PRN MO686770
ETHNICITY Not Hispanic or
Latino
PREF.
LANGUAGE
English
RACE Patient declined
to specify
STATUS Active patient
CONTACT INFORMATION
ADDRESS LINE 1 5432 Rebrow St
ADDRESS LINE 2 –
CITY Lakeside
STATE NY
ZIP CODE 27511
CONTACT BY Home Phone
EMAIL virginiat@testpati
ent.com
HOME PHONE (555) 555-5555
MOBILE PHONE (555) 555-5555
OFFICE PHONE –
OFFICE
EXTENSION
–
FAMILY INFORMATION
NEXT OF KIN George Thompson
RELATION TO PATIENT Spouse
PHONE 5555555555
ADDRESS –
PATIENT’S MOTHER’S
MAIDEN NAME
Holske
Subjective
Sixty-year-old female patient presents with a lesion that doesn’t heal on her left shoulder.
She describes the lesion as a mole that became itchy and has been getting a darker pigment over time. She states that
she first thought it was a “bug bite” that she had been scratching, but the lesion has been present for 4 weeks without
healing. No rashes or other skin complaints.
Objective
Patient’s blood pressure is 128/76.
Patient’s HR is 78 bpm and regular.
Full skin examination reveals several erythematous macules scattered evenly on face and shoulders. Three black,
symmetric, well-demarcated papules are present on the upper back measuring 6mm-1cm.
Encounter – Office Visit Date of service: 04/05/17 Patient: Virgi… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
1 of 2 4/5/17, 4:58 PM
Lesion of concern to the patient is located on the left anterolateral shoulder, 2 cm inferior to the acromioclavicular joint.
It measures 7 mm in diameter and has an asymmetrical, black/brown/red appearance.
Assessment
Multiple benign nevi found the face, trunk, and upper extremities.
Multiple benign papules present across upper back.
Left shoulder lesion shows indications of melanoma.
DDX:
D03.60 Melanoma in situ of unspecified upper limb, including shoulder. C43.60 Malignant melanoma of unspecified
upper limb, including shoulder. D03.62 Melanoma in situ of left upper limb, including shoulder.
Plan
Patient will be referred to dermatologist for biopsy of left shoulder lesion.
Patient is advised to continue use of sunscreen when outdoors.
Follow-up appointments will be scheduled to monitor benign nevi and papules for any suspicious changes.
Free cloud based EHR
Encounter – Office Visit Date of service: 04/05/17 Patient: Virgi… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
2 of 2 4/5/17, 4:58 PM
Module 02 Course Project: Clinical Notes
Each question is associated with the clinical notes provided. Refer to these when answering each question. Please type your answer in the “Click here to enter text” space.
Patient A – Kay June Salisbury
Kay is complaining of lower back pain. What is the medical term used to describe the lower back?
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In the subjective and plan sections of this SOAP note, the abbreviation OTC is used. What does this mean?
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In the objective section of this SOAP note, the doctor noted that the patient has limited flexion in the lumbar spine. Describe what means to “flex” the spine.
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If Kay had also mentioned during this visit that she has been experiencing neck pain, which medical term could be used to describe this complaint? (Use the appropriate suffix for pain)
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The abbreviation ROM is used twice in this SOAP note. What does ROM mean in this context?
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Kay’s physical exam revealed hypertrophy of her muscles. Describe what this means. What is the abnormality present?
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In the assessment section of this document, the abbreviation DDX is used. This is a very commonly used abbreviation. What does DDX stand for?
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The doctor has determined that Kay may have radiculopathy. Describe what this word means in a way that an average patient could understand.
The word “unilateral” is used to describe the possible disk herniation. What does unilateral mean?
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Find an image of a “vertebral disk herniation.” Describe (in your own words) what is happening to the anatomical structures of the spine.
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In the plan section of this SOAP note, the patient is being referred for lumbar and sacroiliac radiography. What does this mean? Define each word: lumbar, sacroiliac, and radiography.
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This patient may need a follow-up MRI. What does this abbreviation stand for?
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Patient B – Virginia Thompson
If Virginia’s physician had noted any dry or scaly skin during this visit, which medical term might he have used to describe it? (Hint: Think about the word roots you studied this week.)
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In the objective section of this SOAP note, the macules are described as “erythematous.” What color is this word referring to?
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The lesion of concern is located in the anterolateral shoulder. How would you describe the location of this lesion in your own words?
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In which section of this SOAP note (Subjective, Objective, Assessment, Plan) do you find a term that means “pertaining to the acromion and clavicle”?
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What is the definition of a “macule”?
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In this SOAP note, the terms “benign” and “malignant” are used to describe both the skin lesions. Define these terms.
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In the plan section of this SOAP note, the doctor plans to perform a biopsy. Briefly describe this procedure.
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Which word found in this SOAP note means “black tumor”?
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Which word found in this SOAP notes refers to a solid, elevated lesion?
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References
You will primarily use your textbook as a reference this week. Provide a citation for your textbook (in APA format) here:
Click here to enter text.
*If you are unfamiliar with APA citation, please see the Rasmussen College APA Guide: http://guides.rasmussen.edu/apa
Select “References” on the left-hand panel and choose “Books” to learn how to properly cite your textbook for this course.
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