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skills/clinical-reports/references/patient_documentation.md

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+# Patient Documentation Standards
+
+## SOAP Notes
+
+SOAP (Subjective, Objective, Assessment, Plan) is the standard format for progress notes in clinical practice.
+
+### Purpose and Use
+
+**When to use SOAP notes:**
+- Daily progress notes in hospital
+- Outpatient visit documentation
+- Subspecialty consultations
+- Follow-up visits
+- Documenting response to treatment
+
+**Benefits:**
+- Standardized structure
+- Organized clinical reasoning
+- Facilitates communication
+- Supports billing and coding
+- Legal documentation
+
+### SOAP Components
+
+#### S - Subjective
+
+**Definition:** Information reported by the patient (symptoms, concerns, history)
+
+**Elements to include:**
+- Chief complaint or reason for visit
+- History of present illness (HPI)
+- Review of systems (ROS) relevant to visit
+- Patient's description of symptoms
+- Response to prior treatments
+- Functional impact
+- Patient concerns or questions
+
+**HPI Elements (use OPQRST for pain/symptoms):**
+- **O**nset: When did it start? Sudden or gradual?
+- **P**rovocation/Palliation: What makes it better or worse?
+- **Q**uality: What does it feel like? (sharp, dull, burning, etc.)
+- **R**egion/Radiation: Where is it? Does it spread?
+- **S**everity: How bad is it? (0-10 scale)
+- **T**iming: Constant or intermittent? Duration? Frequency?
+
+**Associated symptoms:**
+- Other symptoms occurring with primary complaint
+- Pertinent negatives (absence of expected symptoms)
+
+**Response to treatment:**
+- Medications taken and effect
+- Prior interventions and outcomes
+- Compliance with treatment plan
+
+**Example Subjective section:**
+```
+S: Patient reports persistent cough for 5 days, productive of yellow sputum. Associated
+with fever to 101.5°F, measured at home yesterday. Denies shortness of breath, chest
+pain, or hemoptysis. Started on azithromycin 2 days ago by urgent care, with minimal
+improvement. Reports decreased appetite but able to maintain hydration. Denies recent
+travel or sick contacts.
+```
+
+#### O - Objective
+
+**Definition:** Measurable, observable clinical data
+
+**Elements to include:**
+
+**Vital Signs:**
+- Temperature (°F or °C)
+- Blood pressure (mmHg)
+- Heart rate (bpm)
+- Respiratory rate (breaths/min)
+- Oxygen saturation (%)
+- Height and weight (calculate BMI)
+- Pain score if applicable
+
+**General Appearance:**
+- Overall appearance (well, ill, distressed)
+- Age appropriateness
+- Nutritional status
+- Hygiene
+- Affect and behavior
+
+**Physical Examination by System:**
+- Organized head-to-toe or by systems
+- Relevant findings for presenting complaint
+- Include pertinent positives and negatives
+
+**Standard examination systems:**
+1. **HEENT** (Head, Eyes, Ears, Nose, Throat)
+2. **Neck** (thyroid, lymph nodes, JVD, carotids)
+3. **Cardiovascular** (heart sounds, murmurs, peripheral pulses, edema)
+4. **Pulmonary/Respiratory** (breath sounds, work of breathing)
+5. **Abdomen** (bowel sounds, tenderness, organomegaly, masses)
+6. **Extremities** (edema, pulses, ROM, deformities)
+7. **Neurological** (mental status, cranial nerves, motor, sensory, reflexes, gait)
+8. **Skin** (rashes, lesions, wounds)
+9. **Psychiatric** (mood, affect, thought process/content)
+
+**Laboratory and Imaging Results:**
+- Relevant test results
+- Include reference ranges for abnormal values
+- Note timing of tests relative to visit
+
+**Example Objective section:**
+```
+O: Vitals: T 100.8°F, BP 128/82, HR 92, RR 18, SpO2 96% on room air
+General: Alert, mild respiratory distress, appears mildly ill
+HEENT: Oropharynx without erythema or exudates, TMs clear bilaterally
+Neck: No lymphadenopathy, no JVD
+Cardiovascular: Regular rate and rhythm, no murmurs
+Pulmonary: Decreased breath sounds right lower lobe, dullness to percussion, egophony
+present. No wheezes.
+Abdomen: Soft, non-tender, no organomegaly
+Extremities: No edema, pulses 2+ bilaterally
+Neurological: Alert and oriented x3, no focal deficits
+
+Labs (drawn today):
+WBC 14.2 x10³/μL (H) [ref 4.5-11.0]
+Hemoglobin 13.5 g/dL
+Platelets 245 x10³/μL
+CRP 8.5 mg/dL (H) [ref <0.5]
+
+Chest X-ray: Right lower lobe consolidation consistent with pneumonia
+```
+
+#### A - Assessment
+
+**Definition:** Clinical impression, diagnosis, and evaluation of patient status
+
+**Elements to include:**
+- Primary diagnosis or problem
+- Secondary diagnoses or problems
+- Differential diagnosis if uncertain
+- Severity assessment
+- Progress toward treatment goals
+- Complications or new problems
+
+**Format:**
+- Problem list (numbered)
+- Each problem with brief assessment
+- Include ICD-10 codes when appropriate for billing
+
+**Example Assessment section:**
+```
+A: 
+1. Community-acquired pneumonia (CAP), right lower lobe (J18.1)
+   - Moderate severity (CURB-65 score 1)
+   - Appropriate for outpatient management
+   - Minimal improvement on azithromycin, likely bacterial etiology
+   
+2. Dehydration, mild (E86.0)
+   - Secondary to decreased PO intake
+   
+3. Type 2 diabetes mellitus (E11.9)
+   - Well-controlled, continue home medications
+```
+
+#### P - Plan
+
+**Definition:** Diagnostic and therapeutic interventions
+
+**Elements to include:**
+- Diagnostic plan (further testing, imaging, referrals)
+- Therapeutic plan (medications, procedures, therapies)
+- Patient education and counseling
+- Follow-up arrangements
+- Specific instructions for patient
+- Return precautions (when to seek urgent care)
+
+**Medication documentation:**
+- Drug name (generic preferred)
+- Dose and route
+- Frequency
+- Duration
+- Indication
+
+**Plan organization:**
+- By problem (matches assessment)
+- By intervention type (diagnostics, therapeutics, education)
+
+**Example Plan section:**
+```
+P:
+1. Community-acquired pneumonia:
+   Diagnostics: None additional at this time
+   Therapeutics:
+   - Discontinue azithromycin
+   - Start amoxicillin-clavulanate 875/125 mg PO BID x 7 days
+   - Supportive care: adequate hydration, rest, acetaminophen for fever
+   Education: 
+   - Explained bacterial pneumonia diagnosis and antibiotic change
+   - Discussed expected improvement within 48-72 hours
+   - Return precautions: worsening dyspnea, high fever >103°F, confusion
+   Follow-up: Phone call in 48 hours to assess response, clinic visit in 1 week
+   
+2. Dehydration:
+   - Encourage PO fluids, goal 2 liters/day
+   - Sports drinks or electrolyte solutions acceptable
+   
+3. Type 2 diabetes:
+   - Continue metformin 1000 mg PO BID
+   - Home glucose monitoring
+   - Follow-up with endocrinology as scheduled
+
+Patient verbalized understanding and agreement with plan.
+```
+
+### SOAP Note Best Practices
+
+**Documentation standards:**
+- Write legibly if handwritten
+- Use standard abbreviations only
+- Date and time each entry
+- Sign and credential all entries
+- Document in real-time or as soon as possible
+- Avoid copy-forward errors
+- Review and update problem list
+
+**Billing considerations:**
+- Document medical necessity
+- Match documentation to billing level
+- Include required elements for E/M coding
+- Document time for time-based billing
+
+**Legal considerations:**
+- Document facts, not opinions or judgment
+- Quote patient when relevant
+- Document non-compliance objectively
+- Never alter records
+- Use addendums for corrections
+
+## History and Physical (H&P)
+
+### Purpose
+
+- Comprehensive baseline assessment
+- Document patient status at admission or initial encounter
+- Guide diagnosis and treatment planning
+- Required within 24 hours of admission (TJC requirement)
+
+### H&P Components
+
+#### Header Information
+
+- Patient name, DOB, MRN
+- Date and time of examination
+- Admitting diagnosis
+- Attending physician
+- Service
+- Location (ED, floor, ICU)
+
+#### Chief Complaint (CC)
+
+**Definition:** Brief statement of why patient is seeking care
+
+**Format:**
+- One sentence
+- Use patient's own words (in quotes)
+- Example: CC: "I can't catch my breath"
+
+#### History of Present Illness (HPI)
+
+**Purpose:** Detailed chronological narrative of current problem
+
+**Required elements (for billing):**
+- Location
+- Quality
+- Severity
+- Duration
+- Timing
+- Context
+- Modifying factors
+- Associated signs/symptoms
+
+**Structure:**
+- Opening statement (demographics, presenting problem)
+- Chronological description
+- Symptom characterization
+- Prior workup or treatment
+- What prompted presentation now
+
+**Example:**
+```
+HPI: Mr. Smith is a 65-year-old man with history of CHF (EF 35%) who presents with
+3 days of progressive dyspnea on exertion. Patient reports dyspnea now occurs with
+walking 10 feet (baseline 1-2 blocks). Associated with orthopnea (now requiring
+3 pillows, baseline 1) and lower extremity swelling. Denies chest pain, palpitations,
+or syncope. Reports medication compliance but notes running out of furosemide 2 days
+ago. Weight increased 8 lbs over past week. Has not been monitoring daily weights
+at home. Presented to ED today when dyspnea worsened and developed while at rest.
+```
+
+#### Past Medical History (PMH)
+
+**Include:**
+- Chronic medical conditions
+- Previous hospitalizations
+- Major illnesses
+- Injuries
+- Childhood illnesses (if relevant)
+
+**Format:**
+```
+PMH:
+1. Heart failure with reduced ejection fraction (2018), EF 35% on echo 6 months ago
+2. Coronary artery disease, s/p CABG (2019)
+3. Type 2 diabetes mellitus (2010)
+4. Hypertension (2005)
+5. Chronic kidney disease stage 3 (baseline Cr 1.8 mg/dL)
+6. Hyperlipidemia
+```
+
+#### Past Surgical History (PSH)
+
+**Include:**
+- All surgeries and procedures
+- Dates (year acceptable if exact date unknown)
+- Complications if any
+
+**Format:**
+```
+PSH:
+1. CABG x4 (2019), complicated by post-op atrial fibrillation
+2. Cholecystectomy (2015)
+3. Appendectomy (childhood)
+```
+
+#### Medications
+
+**Documentation:**
+- Generic name preferred
+- Dose, route, frequency
+- Indication if not obvious
+- Include over-the-counter medications
+- Herbal supplements
+- Note if patient unable to provide list
+
+**Format:**
+```
+Medications:
+1. Furosemide 40 mg PO daily (ran out 2 days ago)
+2. Carvedilol 12.5 mg PO BID
+3. Lisinopril 20 mg PO daily
+4. Spironolactone 25 mg PO daily
+5. Metformin 1000 mg PO BID
+6. Atorvastatin 40 mg PO daily
+7. Aspirin 81 mg PO daily
+8. Multivitamin daily
+```
+
+#### Allergies
+
+**Document:**
+- Drug allergies with reaction
+- Food allergies
+- Environmental allergies
+- NKDA if no known allergies
+
+**Format:**
+```
+Allergies:
+1. Penicillin → anaphylaxis (childhood)
+2. Shellfish → hives
+3. ACE inhibitors → angioedema
+```
+
+#### Family History (FH)
+
+**Include:**
+- First-degree relatives (parents, siblings, children)
+- Age and health status or age at death and cause
+- Relevant hereditary conditions
+- Family history of presenting condition if relevant
+
+**Format:**
+```
+Family History:
+Father: CAD, MI age 58, alive age 85
+Mother: Breast cancer, deceased age 72
+Brother: Type 2 diabetes
+Sister: Healthy
+Children: 2 sons, both healthy
+```
+
+#### Social History (SH)
+
+**Include:**
+- Tobacco use (current, former, never; pack-years if applicable)
+- Alcohol use (drinks per week, CAGE questions if indicated)
+- Illicit drug use (current, former, never; type and route)
+- Occupation
+- Living situation (alone, with family, assisted living, etc.)
+- Marital status
+- Sexual history (if relevant)
+- Exercise habits
+- Diet
+- Functional status
+
+**Format:**
+```
+Social History:
+Tobacco: Former smoker, quit 10 years ago (30 pack-year history)
+Alcohol: 2-3 beers per week, denies binge drinking
+Illicit drugs: Denies
+Occupation: Retired electrician
+Living situation: Lives at home with wife, 2-story house, bedroom upstairs
+Marital status: Married
+Exercise: Unable to exercise due to dyspnea
+Diet: Low sodium diet (usually adherent)
+Functional status: Independent in ADLs at baseline
+```
+
+#### Review of Systems (ROS)
+
+**Purpose:** Systematic screening for symptoms by body system
+
+**Requirements:**
+- Minimum 10 systems for comprehensive exam
+- Pertinent positives and negatives
+- "All other systems reviewed and negative" acceptable if documented
+
+**Systems:**
+1. **Constitutional**: Fever, chills, night sweats, weight change, fatigue
+2. **Eyes**: Vision changes, pain, discharge
+3. **ENT**: Hearing loss, tinnitus, sinus problems, sore throat
+4. **Cardiovascular**: Chest pain, palpitations, edema, claudication
+5. **Respiratory**: Cough, dyspnea, wheezing, hemoptysis
+6. **Gastrointestinal**: Nausea, vomiting, diarrhea, constipation, abdominal pain
+7. **Genitourinary**: Dysuria, frequency, hematuria, incontinence
+8. **Musculoskeletal**: Joint pain, swelling, stiffness, weakness
+9. **Skin**: Rashes, lesions, itching, changes in moles
+10. **Neurological**: Headache, dizziness, syncope, seizures, weakness, numbness
+11. **Psychiatric**: Mood changes, depression, anxiety, sleep disturbance
+12. **Endocrine**: Heat/cold intolerance, polyuria, polydipsia
+13. **Hematologic/Lymphatic**: Easy bruising, bleeding, lymph node swelling
+14. **Allergic/Immunologic**: Seasonal allergies, frequent infections
+
+**Format:**
+```
+ROS:
+Constitutional: Denies fever, chills. Reports fatigue and weight gain (8 lbs).
+Cardiovascular: Reports dyspnea, orthopnea, lower extremity edema. Denies chest pain,
+palpitations, syncope.
+Respiratory: Denies cough, wheezing, hemoptysis.
+Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation, abdominal pain.
+All other systems reviewed and negative.
+```
+
+#### Physical Examination
+
+**General organization:**
+- Vital signs first
+- General appearance
+- Systematic examination head-to-toe
+
+**Vital signs:**
+```
+Vitals: T 98.2°F, BP 142/88, HR 105, RR 24, SpO2 88% on room air → 95% on 2L NC
+Height: 5'10", Weight: 195 lbs (baseline 187 lbs), BMI 28
+```
+
+**System examinations:**
+
+**General:** Well-developed, obese man in moderate respiratory distress, sitting upright in bed
+
+**HEENT:**
+- Head: Normocephalic, atraumatic
+- Eyes: PERRLA, EOMI, no scleral icterus
+- Ears: TMs clear bilaterally
+- Nose: Nares patent, no discharge
+- Throat: Oropharynx without erythema or exudates
+
+**Neck:** Supple, no lymphadenopathy, JVP elevated to 12 cm, no thyromegaly
+
+**Cardiovascular:**
+- Inspection: No visible PMI
+- Palpation: PMI laterally displaced
+- Auscultation: Tachycardic regular rhythm, S3 gallop present, 2/6 holosystolic murmur at apex radiating to axilla
+- Peripheral pulses: 2+ radial, 1+ dorsalis pedis bilaterally
+
+**Pulmonary:**
+- Inspection: Increased work of breathing, using accessory muscles
+- Palpation: Tactile fremitus symmetric
+- Percussion: Dullness to percussion at bilateral bases
+- Auscultation: Bilateral crackles halfway up lung fields, no wheezes
+
+**Abdomen:**
+- Inspection: Obese, no distention
+- Auscultation: Normoactive bowel sounds
+- Percussion: Tympanic
+- Palpation: Soft, non-tender, no masses, no hepatosplenomegaly
+
+**Extremities:** 3+ pitting edema to mid-calf bilaterally, no cyanosis or clubbing
+
+**Skin:** Warm and dry, no rashes
+
+**Neurological:**
+- Mental status: Alert and oriented to person, place, time
+- Cranial nerves: II-XII intact
+- Motor: 5/5 strength all extremities
+- Sensory: Intact to light touch
+- Reflexes: 2+ symmetric
+- Gait: Deferred due to respiratory distress
+- Cerebellar: Finger-to-nose intact
+
+**Psychiatric:** Anxious affect appropriate to illness, normal thought process
+
+#### Laboratory and Imaging
+
+**Include:**
+- All relevant labs with reference ranges
+- Imaging studies with key findings
+- ECG findings
+- Other diagnostic tests
+
+**Example:**
+```
+Laboratory Data:
+CBC: WBC 8.5, Hgb 11.2 (L), Hct 34%, Plt 245
+BMP: Na 132 (L), K 3.2 (L), Cl 98, CO2 30, BUN 45 (H), Cr 2.1 (H, baseline 1.8), glucose 145
+Troponin: <0.04 (normal)
+BNP: 1250 pg/mL (H, elevated)
+
+Imaging:
+Chest X-ray: Cardiomegaly, bilateral pleural effusions, pulmonary vascular congestion
+consistent with volume overload
+
+ECG: Sinus tachycardia at 105 bpm, left ventricular hypertrophy, no acute ST-T changes
+```
+
+#### Assessment and Plan
+
+**Format:** Problem-based with numbered problem list
+
+**Example:**
+```
+Assessment and Plan:
+
+65-year-old man with history of CHF (EF 35%) presenting with acute decompensated
+heart failure.
+
+1. Acute decompensated heart failure (I50.23)
+   - NYHA Class IV symptoms
+   - Volume overload on exam and imaging
+   - Precipitated by medication non-adherence (ran out of furosemide)
+   - BNP elevated at 1250
+   Diagnostics:
+   - Echocardiogram to assess current EF and valvular function
+   - Daily weights and strict I/O
+   Therapeutics:
+   - Furosemide 40 mg IV BID, goal negative 1-2L daily
+   - Continue carvedilol, lisinopril, spironolactone
+   - Oxygen 2L NC, goal SpO2 >92%
+   - Low sodium diet (<2g/day), fluid restriction 1.5L/day
+   - Telemetry monitoring
+   Follow-up: Will reassess after diuresis, goal discharge in 3-5 days
+
+2. Acute kidney injury on CKD stage 3 (N17.9, N18.3)
+   - Cr 2.1 from baseline 1.8, likely prerenal from poor forward flow
+   - Monitor daily, expect improvement with diuresis
+   - Hold nephrotoxic agents
+
+3. Hypokalemia (E87.6)
+   - K 3.2, likely from prior diuretic use
+   - Replete K 40 mEq PO x1, then reassess
+   - Continue spironolactone for K-sparing effect
+
+4. Hyponatremia (E87.1)
+   - Na 132, likely dilutional from volume overload
+   - Expect improvement with diuresis
+   - Fluid restriction as above
+
+5. Type 2 diabetes mellitus (E11.9)
+   - Well-controlled
+   - Continue home metformin
+   - Monitor glucose while hospitalized
+
+6. Coronary artery disease (I25.10)
+   - Stable, no acute coronary syndrome
+   - Continue aspirin, statin, beta-blocker
+
+Code status: Full code
+Disposition: Admit to telemetry floor
+```
+
+## Discharge Summary
+
+### Purpose
+
+- Communicate hospital care to outpatient providers
+- Document hospital course and outcomes
+- Ensure continuity of care
+- Meet regulatory requirements (TJC, CMS)
+
+### Timing
+
+**Requirements:**
+- Complete within 30 days of discharge (CMS)
+- Many hospitals require within 24-48 hours
+- Available at time of follow-up appointment
+
+### Components
+
+#### Header
+
+- Patient demographics
+- Admission date and discharge date
+- Length of stay
+- Attending physician
+- Consulting services
+- Primary care physician
+
+#### Admission Diagnosis
+
+Principal reason for hospitalization
+
+#### Discharge Diagnosis
+
+**Format:** Numbered list, prioritized
+
+**Example:**
+```
+Discharge Diagnoses:
+1. Acute decompensated heart failure
+2. Acute kidney injury on chronic kidney disease stage 3
+3. Hypokalemia
+4. Hyponatremia
+5. Coronary artery disease
+6. Type 2 diabetes mellitus
+```
+
+#### Hospital Course
+
+**Content:**
+- Chronological narrative or problem-based
+- Key events and interventions
+- Response to treatment
+- Procedures performed
+- Consultations
+- Complications
+- Significant test results
+
+**Example (brief):**
+```
+Hospital Course:
+Mr. Smith was admitted with acute decompensated heart failure in the setting of
+medication non-adherence. He was diuresed with IV furosemide with net negative
+5 liters over 3 days, with significant improvement in dyspnea and resolution of
+lower extremity edema. Echocardiogram showed persistent reduced EF of 30%, similar
+to prior. Kidney function improved to baseline with diuresis. Electrolytes were
+repleted and normalized. Patient was transitioned to oral furosemide on hospital
+day 3 and remained stable. He was ambulating without dyspnea on room air by
+discharge. Comprehensive heart failure education was provided.
+```
+
+#### Procedures
+
+```
+Procedures:
+1. Echocardiogram transthoracic (hospital day 1)
+```
+
+#### Discharge Medications
+
+**Format:**
+- Complete list with instructions
+- **NEW** medications highlighted
+- **CHANGED** medications noted
+- **DISCONTINUED** medications listed
+
+**Example:**
+```
+Discharge Medications:
+1. Furosemide 60 mg PO daily [INCREASED from 40 mg]
+2. Carvedilol 12.5 mg PO BID [UNCHANGED]
+3. Lisinopril 20 mg PO daily [UNCHANGED]
+4. Spironolactone 25 mg PO daily [UNCHANGED]
+5. Metformin 1000 mg PO BID [UNCHANGED]
+6. Atorvastatin 40 mg PO daily [UNCHANGED]
+7. Aspirin 81 mg PO daily [UNCHANGED]
+```
+
+#### Discharge Condition
+
+```
+Discharge Condition:
+Hemodynamically stable, ambulatory, no supplemental oxygen requirement, euvolemic
+on exam, baseline functional status restored.
+```
+
+#### Discharge Disposition
+
+```
+Discharge Disposition:
+Home with self-care
+```
+
+#### Follow-up Plans
+
+**Include:**
+- Appointments scheduled
+- Recommended follow-up timing
+- Pending tests or studies at discharge
+- Referrals made
+
+**Example:**
+```
+Follow-up:
+1. Cardiology appointment with Dr. Jones on [date] at [time]
+2. Primary care with Dr. Smith in 1 week
+3. Home health for vital sign monitoring and medication reconciliation
+4. Repeat BMP in 1 week (arranged, lab slip provided)
+```
+
+#### Patient Instructions
+
+**Include:**
+- Activity restrictions
+- Dietary restrictions
+- Wound care (if applicable)
+- Equipment or home services
+- Monitoring instructions (daily weights, glucose, BP)
+- Return precautions
+
+**Example:**
+```
+Patient Instructions:
+1. Weigh yourself daily every morning, call doctor if gain >2 lbs in 1 day or >5 lbs
+   in 1 week
+2. Low sodium diet (<2 grams per day)
+3. Fluid restriction 2 liters per day
+4. Take all medications as prescribed, do not run out of medications
+5. Activity: Resume normal activities as tolerated
+6. Return to ER or call 911 if: severe shortness of breath, chest pain, severe swelling,
+   or other concerning symptoms
+```
+
+---
+
+This reference provides comprehensive standards for patient clinical documentation including SOAP notes, H&P, and discharge summaries. Use these guidelines to ensure complete, accurate, and compliant clinical documentation.
+