KM HOSPICE SOAP NOTE

Date of Service -[date name="date1" default="today"]Location - [select name="loc" value="Los Angeles County|Riverside County"]
Patients NameDemographics and Patient Status
[textarea name="demo1" default=""]
History of Presenting Illness
[comment memo="write HPI below"]
[textarea name="variable5" default=""]
A palliative consultation was requested by the patients attending hospice physician Dr Khan, to alleviate the burden associated with the following condition/s
Allergies -
[textarea name="allergies_1" default="No Known Allergies"]
Past Surgical History
[textarea name="Surgical1" default="see patient chart"]
Family History -
[textarea name="Family_text" default="See patient chart"]
Social History -
[textarea name="Social_1" default="See patient chart"]
Medication -
[select name="Med1" value="I have reviewed the patients medications and agree with current regiment|"][conditional field="Med1" condition="(Med1).is('')"][textarea name="Medtxt1" default=""][/conditional]
Advanced Care Directives -
Health Care Proxy - [select name="HCP1" value="Yes|No"]
[conditional field="HCP1" condition="(HCP1).is('Yes')"]
[textarea name="HCPtxt1" default=""]
[comment memo="Name, Relationship to patient, Phone number"][/conditional]
[checkbox name="ACD_2" value="Living Will|Documentation of Oral Advance Directive|Durable Power of Attorney|DNR|DNI|No Feeding Tube|Do Not Hospitalize|"][conditional field="ACD_2" condition="(ACD_2).is('')"][textarea name="ACDtext1" default=""]
[comment memo="Discuss any additional information regarding ACD"][/conditional]Change in Patient's Wishes -
[select name="Wish1" value="No|Yes"][conditional field="Wish1" condition="(Wish1).is('Yes')"]
[textarea name="ACDtext1" default=""][/conditional]Review of Systems
[select name="ROS_1" value="This patient is able to provide appropriate answers|This patient is nonverbal/otherwise unable to assess"][conditional field="ROS_1" condition="(ROS_1).is('This patient is able to provide appropriate answers')"]
[comment memo="Default will be negative. Click if positive"]
General
[checklist name="ROS1" value="Sleep Disturbances|Fatigue|Skin Changes|Recent Falls"]
Neurological
[checklist name="ROS2" value="Syncope|Headache|Coordination Changes|Weakness| Numbness"]
HEENT
[checklist name="ROS3" value="Vision Changes|Eye Pain|Nasal Congestion|Nasal Discharge|Hearing Changes|Pain in Ear|Dysphagia|Odynophagia"]
Cardiovascular
[checklist name="ROS4" value="Chest Pain|Palpitations"]
Respiratory
[checklist name="ROS5" value="Dyspnea|Cough|Shortness of Breath"]
Gastrointestinal
[checklist name="ROS6" value="Nausea|Vomitting|Diarrhea|Constipation|Abdominal Pain"]
Genitourinary
[checklist name="ROS7" value="Urinary incontinence|Dysuria"]
Musculoskeletal
[checklist name="ROS8" value="Muscle Weakness|Joint pain|Joint stiffness"]
[/conditional]Physical Exam [comment memo="Please write in Vitals"]
Vital Signs - [textarea name="VS1" default="BP- mmgHg T- °F P- beats/min R- breaths/min"]
General - [textarea name="Pe1" default="No acute distress, Well developed, well nourished, Afebrile"]
Neurological - [textarea name="Pe2" default="Alert and Oriented, Normal mood and affect, Cranial Nerves II-XII grossly intact"]
HEENT - [textarea name="Pe3" default="Head is normocephalic, atraumatic. Bilateral pupils equal and reactive to light and accommodating. No scleral icterus, no conjunctival pallor. No neck masses palpated."]
Pulmonary - [textarea name="Pe4" default="Respiratory effort within normal limits. No crackles. No rhales or rhonchi."]
Cardiovascular - [textarea name="Pe5" default="Distal pulses 2+ in all extremeties. Adequate perfusion. No peripheral signs of cyanosis. Regular rate and rhythm. No murmurs auscultated."]
Gastrointestinal - [textarea name="Pe6" default="Abdomen soft, nontender, nondistended. No guarding or tenderness. Bowel sounds auscultated."]
Musculoskeletal - [textarea name="Mskphys" default="No difficulty with passive ROS Strength 5/5 bilateral upper extremeties. "]
Assessment
[textarea name="Ass1" default=""]
Plan-
[textarea name= "Dr Khan" default="Exact time frame of patient deterioration and eventual death is hard to predict. But severe physical and mental deterioration and eventual passing away is highly likely to happen with in 6 months. Dr Khan has been informed of patient situation and current condition. He agrees with the current plan of admitting/readmitting patient to hospice care. "]
Total time spent
with the patient and/or with the patient's family was approximately [text name="time_1" default="60"] minutes. Greater than 50% of the time was spent counseling, coordinating care for the patient. In addition to obtaining history, examining the patient, reviewing all pertinent diagnosis, diagnostic studies, reviewing active orders, documenting care, I have also spent a significant amount of time counseling the patient on end of life issues, answering questions and coordinating care for the patient