Synopsis
Written specifically for the outpatient FNP, this book is your new guide to format SOAP note documentation, including tips to streamline the SOAP note writing process, primarily through the use of a custom working template.
Updated 2nd Edition Now Includes:
- Tips to Streamline the Documentation Process, Keyboard Tips for Efficient Transcription, Using this Book to Create a Template, Clinical SOAP Note Format, Abbreviations in Notes, Referring to time within notes, Physical Exam Narrative, Full SOAP example. Sports Physical, Pediatric Well Visit Notes
- Supplemental Lab Result Notes: Sample Lab Sets to Order, Iron deficiency, Hypertriglycerides, Pediatric lipid screening, Hyperlipidemia
- SOAP Notes for Common Primary Care Visits:
- Gastrointestinal Complaints: Constipation SOAP, Diarrhea Note, Gastroenteritis Note, GERD Note, Hemorrhoid Note, Rectal Bleed SOAP
- Dermatology Complaints: General Skin Assessment Guidelines, Cellulitis SOAP, Mole SOAP, Rash SOAP, Acne Education Note, Diaper Rash Note, Eczema Note, Keratosis Pilaris Education, Lice Note, Scabies Note, Tinea Ungium Infection Education, Imbedded Tick Education, Varicose Vein Education
- Fatigue and Sleep Health: SOAPs and Sample Blurbs: Fatigue SOAP, Insomnia/Difficulty Sleeping SOAP, OSA Note
- Fever and Viral Infections: Fever Note, Mononucleosis SOAP, URI SOAP, Influenza Note
- Headache & Migraine: Headache SOAP, Migraine SOAP
- Head, Ears, Nose & Throat: Acute Otitis Media SOAP, Acute Otitis Externa Note, Concussion Follow-Up Note, Conjunctivitis SOAP, Cerumen Impaction SOAP, Strep Pharyngitis SOAP, Bronchitis Education Note, Tonsil Stone Education Note
- Hypertension: Pre-hypertension Education, New Diagnosis of HTN SOAP, Hypertension follow-up SOAP
- Joint Health/Pain: Sample Blurbs: Carpal Tunnel Note, Gout Education, Raynaud Education, Rheumatoid/Autoimmune Workup Note, Chondromalacia/Runner’s Knee Note
- Lifestyle Modification & Weight Management: Weight loss education note, Obesity note, Bariatric Surgery Initial Visit SOAP, s/p Bariatric Surgery Follow-Up Note, Pre-Diabetes SOAP, Smoking Cessation SOAP
- Mental Health: ADD/ADHD SOAP, ETOH/Alcohol Abuse & Misuse Note, Anxiety Note, Depression Note
- Orthopedics & Musculoskeletal: Arthritis SOAP, Ankle pain SOAP, Back Pain Note, Hip Pain Note, De Quervain’s Tenosynovitis Education Note, Knee Pain Education, Myalgia Education, Neck Pain Education, SI Joint Note, Osteopenia Education, Sprain Education, Tennis Elbow Education, Shoulder Pain SOAP, TMJ Note
- Pain Management: Acute Back Pain Note, Chronic Back Pain Note, Acute on Chronic Back Pain SOAP, Nonpharmacological Pain Management Noes
- Podiatry Sample Blurbs: Ingrain Toenail, Plantar Fasciitis, Plantar Warts
- Sexual & Reproductive Health: Amenorrhea SOAP, Abnormal Uterine Bleeding Note, Bacterial Vaginitis Note, Dyspareunia Note, Pregnancy Note, Erectile Dysfunction Note, Genital Herpes Note, STI Exposure SOAP, UTI SOAP, Vaginal Discharge Note, Yeast Infection Note
- General Contraceptive Notes, Oral contraceptives, IUD, Nexplanon, Patch, Ring
- Sexual Health Screening Notes: Breast Cancer Screening Note &STI Screening Note
- Procedure Notes, to include Incision & Drainage Procedure, Nexplanon Insertion, Shave Biopsy, Steroid Injection Procedure, PAP Smear, and Wart Destruction Procedure
"synopsis" may belong to another edition of this title.