This assignment requires documentation of 160 seperate field encounters for individual patients(ages 0-90 years old) in a primary healthcare clinic. Field encounter entries should follow a brief SOAP format when entering your field encounters. Here are a couple of “Exemplar” Patient Field Encounters that meet expectations for this course. They are simple and straightforward (modified & concise SOAP type format), please make sure your 160 different field encounters reflect this type of format.
Age: 41 Years
Gender: F
Chief Complaint: Follow-up for my hypertension and hyperlipidemia
Plan of Care: Patient presents for follow-up appointment for diagnosis of hypertension and hyperlipidemia. BP 118/70, HR 86, RR 18, Temp 98.7. Patient denies headaches. Patient states she has been trying to eat better but has had difficulty giving up some of her favorite foods. Patient also complains of rhinorrhea. Postnasal drip noted to throat, pharynx mild erythema, tonsils 1+ bilaterally with no exudate, nares mucosa mild erythema bilaterally; pt denies cough. No lymphadenopathy noted. Lung sounds clear all lobes. Cardiac S1 S2 heard with no murmer. Patient states she uses her rescue inhaler once a week at most. Plan: Patient will continue to take Lovastatin 40mg daily. Unable to obtain labs as patient is not fasting. Patient to continue on Lisinopril 10mg daily. Continue to check blood pressure at home. Return to clinic if blood pressure is 130/80 or greater, more than 2-3 days in a row. Restarted Singulair 10mg once every evening. Continue taking Claritin each morning. Avoid allergens when possible. Continue to use ProAir HFA rescue inhaler as needed for asthma exacerbation. Patient will go to lab Friday to draw CMP, A1c, and fasting lipid panel. Educated patient on Cardiac Diet. Follow-up in two weeks for blood pressure recheck.
CPT/ICD-10: CPT 99214; ICD 10 E78.5 Hyperlipidemia, I10 Essential hypertension, J45.21 Mild intermittent asthma with exacerbation, R09.82 Postnasal drip.
Student Comments: 1 of 10 (this is counting the cases you have for the day – this is 1st field encounter for day).
Age: 74 Years
Gender: F
Chief Complaint: Follow-up appointment for my diabetes
Plan of Care: Patient is doing well, denies any problems with blood sugar or current symptoms. Blood pressure 116/78, HR 72, RR 16, Temp 98.2. Lung sounds clear all lobes. Cardiac S1 S2 heard with no murmur. No peripheral edema noted. Pedal pulse 3+ bilaterally. No sores noted to bilateral feet. Feet well-groomed. Denies peripheral numbness or tingling. Denies trouble with vision. Last eye exam within last 6 months. Plan: Continue taking Lisinopril 10mg daily for blood pressure. Continue following diabetic diet low in sodium; educated patient on diet. Continue taking Januvia 100mg by mouth daily. CBC, CMP, A1c, fasting lipid panel, and TSH to be drawn today. Follow-up in 6 months. Return to clinic for any problems.
CPT/ICD-10: CPT 99214; ICD 10 E11.9 Type 2 diabetes mellitus without complications, I10 Essential hypertension.
Student Comments: 2 of 10 (this is counting the cases you have for the day – this is 2nd field encounter for day).