A 31-year-old white male comes in for an evaluation of his allergic rhinitis.
He is known to your practice for the last decade.
Presently he is on Flonase nasal spray and Zyrtec daily for his allergic rhinitis.
He owns his own business ‘Dr. Vinyl’ where he specializes in repair of vinyl in automobiles, boats, recreational vehicles, etc.
Exposure to the smell of several of the products he works with has resulted in dissatisfactory management of his typical allergic rhinitis.
On numerous occasions over the last decade he has requested and been given an ‘allergy shot’.
A review of his medical record reveals to you this ‘shot’ has been a steroid injection.
BP 122/74, P 76, R 18
Construct your response as an abbreviated SOAP note (Subjective Objective Assessment Plan).
Structure your ‘P’ in the following format: [NOTE: if any of the 3 categories is not applicable to your plan please use the ‘heading’ and after the ‘:’ input N/A]
Therapeutics: pharmacologic interventions, if any – new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative); [optional – any other therapies in lieu of pharmacologic intervention]
Educational: health information clients need to address their presenting problem(s); health information in support of any of the ‘therapeutics’ identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit
Consultation/Collaboration: if appropriate – collaborative ‘Advanced Care Planning’ with the patient/patient’s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate – consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making
Support the interventions outlined in your ‘P’ with scholarly resources.
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