Medical Documentation Proofreading Example 16 - Whole SOAP Report
Proofread the SOAP report below.
Sample Name: Blood in Urine - ER Visit
Description: The patient has prostate cancer with metastatic disease on his bladder. The patient has had problems with hematuria in past. The patient was encouraged to drink extra water and was given discharge instructions of hematuria.
SUBJECTIVE
CHIEF COMPLIANT: Blood in urine.
HISTORY OF PRESENT ILLNESS: This is a 78-years-old male who has a prostate cancer with metastatic disease to his bladder and in several location throughout skeletal system, including the spine, shoulder. The patient has had problems with hematuria in the past but the patient noted that this episode began yesterday, and today he has been passing principaly blood with very little urine. The patient tells that there is no change in her chronic lower back pain, and denies any incontinence of urine and stool. The patient has not have any fever. There is no abdomenal pain, and the patient is still able to pass a urine. The patient has not had any melena or hematochezia. There is no nausea or vomitting. The patient has already completed chemotherapy and is beyond treatment for his cancer at that time. The patient is recieving radiation therapy, but it is intended to give symptomatic relieve of his skeletal pain and not intended to treat and cure the cancer.
REVIEW OF SYSTEMS:
CONSTITUTIONAL- No fever or chills. The patient does reports generalized fatigue and weakness over the past several days.
HEENT: No headache, no neck pain, no rhinorrhea, no soar throat.
CARDIOVASCULAR: No chest pain.
RESPIRATIONS: No shortness of breath or cough. However, the patient does get easily wind with exertion over the past few days.
GASTROINTESTINAL: The patient denies any abdominal pain. No nausea, or vomiting. No changes in the bowl movement.
MUSCULOSKELETAL: The chronic lower-back pain has not changed over the past few days. The patient does have multiple other joints, which causes him discomfort, but there has been no recent changes in these either.
SKIN: No rashes or lesions, No easy bruising.
NEUROLOGIC: No focal weekness or numbness.
PAST MEDICAL HISTORY: Prostate cancer with metastatic disease as previous described.
PAST SURGICAL HISTORY: TURP
CURRENT MEDICATIONS: Morphine, Darvocet, Flomax, Avodart and ibuprofen.
ALLERGIES: VICODIN.
SOCIAL HISTORY: The patient is a non smoker. Denies any alcohol or illicit drug use. The patient does live with his family.
OBJECTIVE/PHYSICAL EXAMINATION
VITAL SIGNS: temperature is 98.8 oral, blood pressure is 108 65, pulse is 109, Respirations 16, oxygen saturation is 97% on room air and interpreted as normal.
CONSTITUTIONAL: The patient is well-nourished, well developed. The patient appears to be pale but otherwise look well. The patient is calm and comfortable. The patient is pleasant and cooperative.
HEENT: Eyes normal with clearly conjunctivae and corneas. Nose is normal without rhinorrhea or edible congestion. Mouth and oropharynx normal without any sign for infection. Mucous membranes are moist. NECK: Suple. Full range of motion.
CARDIOVASCULAR: Heart is mildly tachycardic with regular rhythm without murmur, rub, and gallop.
RESPIRATIONS: Clear to auscultation bilateral. No shortness of breadth. No wheezes, rales, or rhonchi. Good air movement bilaterally.
GASTROINTESTINAL: Abdomen is soft, nontender, nondistented. Normal bowel sounds. No bruit. No masses or pulsatile masses.
MUSCULOSKELETAL: Back is normal and nontender. There are no abnormality noted to the arms or legs. The patient has normal use of the extremities.
SKIN: The patient appears to be pale, but otherwise the skin is normal. There are no rashes or lesions. NEUROLOGIC: Motor and sensory are intact in the extremities. The patient has normal speech. PSYCHIATRIC: The patient is alert, and oriented.
EMERGENCY DEPARTMENT TESTING: CBC was done, which had a Hemoglobin of 7.7 and hematocrit of 22.6. Neutrophils were 81%. The RDW was 18.5, and the rest of the values was all within the normal limits and unremarkable. Chemistry had a sodium of 134. a glucose of 132, calcium is 8.2, and the rest of the values are unremarkable. Alkaline phosphatase was 770; and albumin was 2.4. The rest of the values all were within the normal limits of the LFT’s. Urinalysis was grossly bloody with a large amount of blood and greater than 50 rbcs.
ASSESSMENT/IMPRESSION/DIAGNOSES
1. HEMATURIA.
2. PROSTATE CANCER WITH BONE AND BLADDER METASTATIC DISEASE.
3. SIGNIFICANT ANEMIA.
4. URINERY OBSTRUCTION.
PLAN
We will have the patient followup with Dr. Cureson in his office in 2 day for revaluation. The patient was gave a prescription of Levaquin and Phenergan tablets to take home with him tonight. The patient was encouraged to drink extra-water. The patient was given discharge instructions on Hematuria and asked to return to the emergency room should he had any worsening of his condition or develop any other problems or symptoms for concern.
Answer
Sample Name: Blood in Urine - ER Visit
Description: The patient has prostate cancer with metastatic disease to his bladder. The patient has had problems with hematuria in the past. The patient was encouraged to drink extra water and was given discharge instructions on hematuria.
SUBJECTIVE
CHIEF COMPLAINT: Blood in urine.
HISTORY OF PRESENT ILLNESS: This is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system, including the spine and shoulder. The patient has had problems with hematuria in the past, but the patient noted that this episode began yesterday, and today, he has been passing principally blood with very little urine. The patient states that there is no change in his chronic lower back pain and denies any incontinence of urine or stool. The patient has not had any fever. There is no abdominal pain, and the patient is still able to pass urine. The patient has not had any melena or hematochezia. There is no nausea or vomiting. The patient has already completed chemotherapy and is beyond treatment for his cancer at this time. The patient is receiving radiation therapy, but it is intended to give symptomatic relief of his skeletal pain and not intended to treat or cure the cancer.
REVIEW OF SYSTEMS
CONSTITUTIONAL: No fever or chills. The patient does report generalized fatigue and weakness over the past several days.
HEENT: No headache, no neck pain, no rhinorrhea, no sore throat.
CARDIOVASCULAR: No chest pain.
RESPIRATIONS: No shortness of breath or cough. However, the patient does get easily winded with exertion over the past few days.
GASTROINTESTINAL: The patient denies any abdominal pain. No nausea or vomiting. No changes in the bowel movement.
MUSCULOSKELETAL: The chronic lower back pain has not changed over the past few days. The patient does have multiple other joints, which cause him discomfort, but there have been no recent changes in these either.
SKIN: No rashes or lesions. No easy bruising.
NEUROLOGIC: No focal weakness or numbness.
PAST MEDICAL HISTORY: Prostate cancer with metastatic disease as previously described.
PAST SURGICAL HISTORY: TURP.
CURRENT MEDICATIONS: Morphine, Darvocet, Flomax, Avodart, and ibuprofen.
ALLERGIES: VICODIN.
SOCIAL HISTORY: The patient is a nonsmoker. Denies any alcohol or illicit drug use. The patient does live with his family.
OBJECTIVE/PHYSICAL EXAMINATION
VITAL SIGNS: Temperature is 98.8, blood pressure is 108/65, pulse is 109, respirations 16, oxygen saturation is 97% on room air and interpreted as normal.
CONSTITUTIONAL: The patient is well nourished, well developed. The patient appears to be pale but otherwise looks well. The patient is calm and comfortable. The patient is pleasant and cooperative.
HEENT: Eyes normal with clear conjunctivae and corneas. Nose is normal without rhinorrhea or audible congestion. Mouth and oropharynx normal without any sign of infection. Mucous membranes are moist. NECK: Supple. Full range of motion.
CARDIOVASCULAR: Heart is mildly tachycardic with regular rhythm without murmur, rub, or gallop.
RESPIRATIONS: Clear to auscultation bilaterally. No shortness of breath. No wheezes, rales, or rhonchi. Good air movement bilaterally.
GASTROINTESTINAL: Abdomen is soft, nontender, nondistended. Normal bowel sounds. No bruit. No masses or pulsatile masses.
MUSCULOSKELETAL: Back is normal and nontender. There are no abnormalities noted to the arms or legs. The patient has normal use of the extremities.
SKIN: The patient appears to be pale, but otherwise, the skin is normal. There are no rashes or lesions. NEUROLOGIC: Motor and sensory are intact in the extremities. The patient has normal speech. PSYCHIATRIC: The patient is alert and oriented.
EMERGENCY DEPARTMENT TESTING: CBC was done, which had a hemoglobin of 7.7 and hematocrit of 22.6. Neutrophils were 81%. The RDW was 18.5, and the rest of the values were all within the normal limits and unremarkable. Chemistry had a sodium of 134, a glucose of 132, calcium is 8.2, and the rest of the values are unremarkable. Alkaline phosphatase was 770, and albumin was 2.4. The rest of the values all were within the normal limits of the LFTs. Urinalysis was grossly bloody with a large amount of blood and greater than 50 rbc's.
ASSESSMENT/IMPRESSION/DIAGNOSES
1. HEMATURIA.
2. PROSTATE CANCER WITH BONE AND BLADDER METASTATIC DISEASE.
3. SIGNIFICANT ANEMIA.
4. URINARY OBSTRUCTION.
PLAN
We will have the patient follow up with Dr. Cureson in his office in 2 days for reevaluation. The patient was given a prescription for Levaquin and Phenergan tablets to take home with him tonight. The patient was encouraged to drink extra water. The patient was given discharge instructions on hematuria and asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern.
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