Outpatient Osteopathic SOAP Note Form Series Usage Guide
OutpatientOsteopathic SOAP NoteForm SeriesUsage GuideSecond EditionPublished by3500 DePauw Boulevard, Suite 1100Indianapolis, IN 46268(317) 879-1881www.academyofosteopathy.org
General Table of ContentsSection Forms. 1Usage Guide . 5Example Forms . 14Blank Forms . 18Complete Table of ContentsSection FormsOutpatient Health Summary Form . 1Outpatient Osteopathic SOAP Note History Form (Page 1 of 3) . 2Outpatient Osteopathic SOAP Note Exam Form (Page 2 of 3). 3Outpatient Osteopathic Assessment and Plan Form (Page 3 of 3) . 4Usage GuideInitial Page: Outpatient Health SummarySection I: Identification and DispositionPatient’s Name . 5Date . 5Update . 5Date of Birth. 5Sex. 5Phone Numbers . 5Marital Status . 5Significant Others. 5DNR or Resuscitate and Qualifications. 5Religion . 5Next of Kin. 5Section II: Social and Family HistorySocial History . 5Employment. 5Occupation . 6Education . 6Tobacco . 6ETOH. 6Drugs . 6Sex Hx . 6Family History. 6Section III: Past Medical HistoryPast Medical History . 6CPT # . 6Start Date of Problem . 6Problem/Diagnosis . 6Medications . 6Start Date for Medications . 6Stop Date for Medications . 6Allergies, Adverse Drug Reactions . 6
Section IV: Health MaintenanceParameter and Dates . 6Section V: Past Surgical HistoryDate and Type . 6Section VI: ConsultantsConsultants . 6"S" Page 1 of 3 Outpatient Osteopathic SOAP Note History FormSection I: Patient’s Name and Date, Patient’s Pain Analog Scale and CCPatient’s Name and Date . 7Boxes—for Office Use . 7Patient’s Pain Analog Scale . 7CC (Chief Complaint) . 7Section II: History of Present Illness and Systems and Past History of Medical, Family, and Social HistoryHistory of Present Illness (HPI) . 7Level of HPI . 7Review of Systems (ROS). 7Level of ROS . 7Past Medical, Family and Social History (PFSH) . 8Level of PFSH . 8Overall History Level . 8Signature of examiner . 8"O" Page 2 of 3: Outpatient Osteopathic SOAP Note Exam FormSection I: Patient’s Name, Date and Vital SignsPatient’s Name . 8Date . 8Sex. 8Vital Signs . 8Boxes—for Office Use . 8Section II: Objective Section (continued as blank lines)Section III. Horizontal Planes and Level of GMSHorizontal Planes . 9Level of GMS (General Multi-System). 9Section IV: Musculoskeletal TableMethod Used to Examine . 9Region Evaluated . 9Severity . 10Somatic Dysfunction and Other Systems . 10Signature of examiner . 10"A" Page 3 of 3: Outpatient Osteopathic Assessment and Plan FormSection I: Patient’s Name, DatePatient’s Name . 10Date . 10Boxes—for Office Use . 10
Section II: Diagnosis and Evaluation Prior to TreatmentDx No, (diagnosis number) . 10ICD Code . 11Written Diagnosis. 11Physician’s Evaluation of Patient Prior to Treatment . 11First Visit . 11Resolved . 11Improved . 11Unchanged . 11Worse . 11"P" Plan of TreatmentSection III: Region, OMT, Treatment Method and ResponseRegion . 11OMT . 11Treatment Method . 11Response . 12Section IV: Other Treatment Methods UsedMeds . 12Exercise . 12Nutrition . 12PT . 12Other . 12Section V: CodingComplexity/Assessment/Plan (Scoring) . 12Problems . 12Risk . 12Data. 12Traditional Method—Coding by Components . 12Optional Method—Coding by Time . 13Section VI: Minutes Spent With the Patient and Follow-up, OMT Performed (number of areas),Other Procedures Performed and E/M CodeTotal Minuets with Patient . 13Follow-up and Units . 13OMT Performed (number of areas) . 13Other Procedures Performed . 13E/M Code . 13Signature of Examiner. 13Example FormsOutpatient Health Summary Form . 14Outpatient Osteopathic SOAP Note History Form (Page 1 of 3) . 15Outpatient Osteopathic SOAP Note Exam Form (Page 2 of 3). 16Outpatient Osteopathic Assessment and Plan Form (Page 3 of 3) . 17Blank FormsOutpatient Health Summary Form . 18Outpatient Osteopathic SOAP Note History Form (Page 1 of 3) . 19Outpatient Osteopathic SOAP Note Exam Form (Page 2 of 3). 20Outpatient Osteopathic Assessment and Plan Form (Page 3 of 3) . 21
Outpatient Health Summary
Outpatient Osteopathic SOAP Note Form Series Second Edition Published by 3500 DePauw Boulevard, Suite 1100 Indianapolis, IN 46268 (317) 879-1881
SOAP Note-Infant SOAP Note-Child SOAP Note-Adolescent SOAP Note-Adult SOAP Note-Geriatric SOAP Note-Obstetric SOAP Note-Gynecologic SOAP Note-Behavior/Psych 3 6 7 . PROCEDURES (required) Procedure Preceptor Initials Date Surgical Gowning/Gloving Surgical Gowning/Gloving Incision and Drainage .
1 The Osteopathic GME Match Report, for the 2011 Match Introduction . The American Association of Colleges of Osteopathic Medicine (AACOM), in cooperation with the American Osteopathic Association (AOA) and the National Board of Osteopathic Medical Examiners, Inc. (NBOME), compiled The Osteopathic GME Matc
the role of the Osteopathic International Alliance 6 the World health Organization and osteopathic practice 7 structure of this report 7 Chapter 1: The concept, history and spread of 8 osteopathic healthcare What is osteopathic healthcare? 9 The range of manual techniques 10 the origins and dissemination of osteopathic practice 11
peach-tangerine soap. The best moisturizer was also the peach-tangerine soap, and for getting rid of dirt the lavender AND peach-tangerine soaps tied. For hands feeling clean the avocado soap came out to be the best. The most fragrant soap turned out to be the "Irish Spring" soap, and the best colored soap was the baby soap.
The American Osteopathic Board of Radiology will not require a written attestation as a requirement for examination or certification. No. 11 In the osteopathic profession, the American Osteopathic Board of Radiology reviews and approves the eligibility of candidates whose training has been reviewed and approved by the American Osteopathic College of Radiology (AOCR). In 1982, the AOCR training .
Burrell College of Osteopathic Medicine (BCOM), New Mexico Campbell University Jerry M. Wallace School of Osteopathic Medicine (CUSOM), North Carolina Chicago College of Osteopathic Medicine of Midwestern University (CCOM/MWU), Illinois Des Moines University - College of Osteopathic Medicine (DMU-COM), Iowa
Agriculture in soap: Plant oils matter You use soap everyday. Where does it come from? What are the ingredients? Soap made from soybeans? Sunflowers? Olives? Plant oils have different “fatty acids” that determine the characteristics of your soap—is it creamy? bubbly? hard? soft? It is the oil in plants that makes different kinds of soap.
The Handbook has been prepared for University students as the textbook in English Phonetics. It can as well be used by the teachers and students of English at any level as a ‘guide’ to correct pronunciation. I am very grateful to my colleagues for reading the draft and giving me valuable recommendations for improving the material. 6 Section A THEORY What are the English sounds and how do .
