Subjective/History Elements
Share
Tweet
Cite
Click to rate this SOAPnote
[Total: 0 Average: 0]
approximately 0 views since I went to an equestrian event just to tell someone to get down off of their high horse.
CC: SARS CoV 2 - Consult - antibody screening

Subjective
This visit was performed via telemedicine.
The patient confirmed knowledge of the limitations of the use of telemedicine were verbally confirmed by the provider.
Verification of patient identity was established and verbal consent for treatment obtained.

Pt is inquiring about COVID 19 IGG antibody testing, reports having unexplained URI symptoms 2 months.

No symptoms at this time.

Past Medical History: None
Past Surgical History: None
Social History: Denies tobacco , etoh social, denies illicits.
--------------------------------------------------------------------------------
Allergies No known allergies
Medications: None

ROS:
6 systems neg

Phone exam:
GEN: Alert, calm, conversant in NAD
HEENT: No dysphonia.
RESP: Unlabored respirations, speaking in full sentences
NEURO: Normal speech. Alert and oriented.
PSYCH: Normal mood. Normal insight and judgement.

Assessment/ Plan:
Encounter for antibody response examination (Z01.84/V72.61) Encounter for antibody
response examination

LABS/STUDIES:
SARS CoV 2 SEROLOGY (COVID 19) AB (IGG), IA

Per pt request , IGG antibody test ordered via quest lab. Limitation discussed COVID 19 and education is given.
CC: SARS CoV 2 - Consult - antibody screening

Subjective
This visit was performed via telemedicine.
The patient confirmed knowledge of the limitations of the use of telemedicine were verbally confirmed by the provider.
Verification of patient identity was established and verbal consent for treatment obtained.

Pt is inquiring about COVID 19 IGG antibody testing, reports having unexplained URI symptoms 2 months.

No symptoms at this time.

Past Medical History: None
Past Surgical History: None
Social History: Denies tobacco , etoh social, denies illicits.
--------------------------------------------------------------------------------
Allergies No known allergies
Medications: None

ROS:
6 systems neg

Phone exam:
GEN: Alert, calm, conversant in NAD
HEENT: No dysphonia.
RESP: Unlabored respirations, speaking in full sentences
NEURO: Normal speech. Alert and oriented.
PSYCH: Normal mood. Normal insight and judgement.

Assessment/ Plan:
Encounter for antibody response examination (Z01.84/V72.61) Encounter for antibody
response examination

LABS/STUDIES:
SARS CoV 2 SEROLOGY (COVID 19) AB (IGG), IA

Per pt request , IGG antibody test ordered via quest lab. Limitation discussed COVID 19 and education is given.

Result - Copy and paste this output:

Send Feedback for this SOAPnote

This site uses Akismet to reduce spam. Learn how your comment data is processed.

More SOAPnotes by this Author: