Tiffany Partin SOAP note #2
Name: P. Ramey Date : 6/4/2019 Time : 1030
DOB: 01/07/1950 Sex: Female
Subjective
CC: “I’m here today to have my annual physical and labs drawn.”
HPI: 69yo WF here today for Medicare Annual Wellness Exam. She reports there have been no
changes to her chronic medical conditions, and that her medication remains therapeutic. She
continues to adhere to a diet specific to diverticulosis management which is therapeutic as
evidence by no recent episodes of diverticulitis. She continues to do 90 minutes of water
aerobics 3 days a week and walks daily for 1 hour.
Instrumental Activities of Daily Living (IADL) were assessed using the Care of Older Adult
(COA) form completed by patient. She reports her cognitive status as excellent. She ambulates
well; without assistance and can climb stairs independently. She states her vision and hearing
are also excellent. Patient reports performing all ADLs including dressing, eating, bathing,
toilet use and transferring (i.e. getting in and out of chairs) independently without difficulty.
Henrich fall risk assessment reviewed and scored (Pt score- 0). Patient reports she does all her
housekeeping, grocery shopping, and medication management independently. Patient states she
is working on an advanced directive with her daughter.
Medications: Vitamin D3 5,000units once a week.
Allergies: Sulfa Drugs (moderate) causes rash/ hives
PMI
Illnesses/Injuries
Childhood- Broken leg at 7yo.
Adult- Diverticulosis, Vitamin D deficiency, Osteoporosis.
Hospitalizations/Surgeries: Total hysterectomy (2008), hospitalized twice for diverticulitis
(11/2016 & 4/2017)
Vaccinations
Influenza- 8/2018 Pneumovac- 4/2017 Tetanus- > 5 years
Health Maintenance:
Complete physical exam- 5/2018
Eye exam- 2/2017
Routine lab work- 5/2018
Last mammogram- 4/2018
Last pap smear- Total Hysterectomy
Last colonoscopy- 1/ 2018
FH:
Stroke- None
This study source was downloaded by 100000900703063 from CourseHero.com on 02-09-2026 16:20:14 GMT -06:00
https://www.coursehero.com/file/76767770/Medicare-Wellness-Exam-SOAP-notedocx/
, Tiffany Partin SOAP note #2
Diabetes-None
Lung disease- None
HTN- None
Heart disease- None
Cancer- Mother died from colon cancer at age 77
SH: Patient is retired postal worker and lives alone. Daughter lives next door.
Tobacco- Denies ETOH- Denies Illicit drugs- Denies
ROS
General: General: Denies weight change, Breast/chest: Denies skin changes,
fatigue, weakness, fever, chills, or night masses/lumps, pain, discharge, or changes
sweats. noticed on self-exams.
Skin: Denies any skin, hair, nail changes, Gastrointestinal: Denies change in appetite,
itching, rashes, sores, lumps, or moles. nausea, vomiting, indigestion, dysphagia,
bowel movement frequency, change in BM,
stool color, diarrhea, constipation, bleeding,
melena, abdominal pain, jaundice, hepatitis.
Eyes: No changes in vision, double vision, Genitourinary/Gynecological: Denies
tearing, itching, or blurry vision. Patient frequency, hesitancy, urgency, polyuria,
wearing glasses for vision correction. dysuria, hematuria, nocturia, incontinence,
stones, or infection. Denies vaginal pain, or
discharge
Ears: Denies hearing loss, tinnitus, vertigo, Hematologic/lymphatic/immunologic: Denies
discharge, or earache. any bruising/ bleeding tendency or frequent
infections.
Nose/Mouth/Throat: Denies rhinorrhea, Musculoskeletal: Denies muscle weakness,
stuffiness, sneezing, itching, allergy, pain, joint stiffness, ROM, instability, redness
epistaxis, bleeding gums, hoarseness, sore swelling arthritis, gout.
throat, swollen lymph nodes
Cardiovascular: Denies murmurs, angina, Neurological: Denies loss of sensation,
palpitations, dyspnea on exertion, orthopnea, tingling, tremors, weakness, fainting, or
PND, edema seizures. Denies impared memory, or difficulty
concentrating.
Respiratory: Denies shortness of breath, Psychiatric: Denies any changes in mood, sleep
wheezing, cough, sputum, hemoptysis, disturbances or psychiatric issues. DAST
pneumonia, asthma, bronchitis screening and PHQ-9 questionnaire reviewed
and documented.
Objective
Wt: 169f Temp: 98.7 Pulse: 80
Ht: 5ft 4in BP: 127/60 Oxygen sat: 100% Resp: 18
Physical Exam
This study source was downloaded by 100000900703063 from CourseHero.com on 02-09-2026 16:20:14 GMT -06:00
https://www.coursehero.com/file/76767770/Medicare-Wellness-Exam-SOAP-notedocx/
Name: P. Ramey Date : 6/4/2019 Time : 1030
DOB: 01/07/1950 Sex: Female
Subjective
CC: “I’m here today to have my annual physical and labs drawn.”
HPI: 69yo WF here today for Medicare Annual Wellness Exam. She reports there have been no
changes to her chronic medical conditions, and that her medication remains therapeutic. She
continues to adhere to a diet specific to diverticulosis management which is therapeutic as
evidence by no recent episodes of diverticulitis. She continues to do 90 minutes of water
aerobics 3 days a week and walks daily for 1 hour.
Instrumental Activities of Daily Living (IADL) were assessed using the Care of Older Adult
(COA) form completed by patient. She reports her cognitive status as excellent. She ambulates
well; without assistance and can climb stairs independently. She states her vision and hearing
are also excellent. Patient reports performing all ADLs including dressing, eating, bathing,
toilet use and transferring (i.e. getting in and out of chairs) independently without difficulty.
Henrich fall risk assessment reviewed and scored (Pt score- 0). Patient reports she does all her
housekeeping, grocery shopping, and medication management independently. Patient states she
is working on an advanced directive with her daughter.
Medications: Vitamin D3 5,000units once a week.
Allergies: Sulfa Drugs (moderate) causes rash/ hives
PMI
Illnesses/Injuries
Childhood- Broken leg at 7yo.
Adult- Diverticulosis, Vitamin D deficiency, Osteoporosis.
Hospitalizations/Surgeries: Total hysterectomy (2008), hospitalized twice for diverticulitis
(11/2016 & 4/2017)
Vaccinations
Influenza- 8/2018 Pneumovac- 4/2017 Tetanus- > 5 years
Health Maintenance:
Complete physical exam- 5/2018
Eye exam- 2/2017
Routine lab work- 5/2018
Last mammogram- 4/2018
Last pap smear- Total Hysterectomy
Last colonoscopy- 1/ 2018
FH:
Stroke- None
This study source was downloaded by 100000900703063 from CourseHero.com on 02-09-2026 16:20:14 GMT -06:00
https://www.coursehero.com/file/76767770/Medicare-Wellness-Exam-SOAP-notedocx/
, Tiffany Partin SOAP note #2
Diabetes-None
Lung disease- None
HTN- None
Heart disease- None
Cancer- Mother died from colon cancer at age 77
SH: Patient is retired postal worker and lives alone. Daughter lives next door.
Tobacco- Denies ETOH- Denies Illicit drugs- Denies
ROS
General: General: Denies weight change, Breast/chest: Denies skin changes,
fatigue, weakness, fever, chills, or night masses/lumps, pain, discharge, or changes
sweats. noticed on self-exams.
Skin: Denies any skin, hair, nail changes, Gastrointestinal: Denies change in appetite,
itching, rashes, sores, lumps, or moles. nausea, vomiting, indigestion, dysphagia,
bowel movement frequency, change in BM,
stool color, diarrhea, constipation, bleeding,
melena, abdominal pain, jaundice, hepatitis.
Eyes: No changes in vision, double vision, Genitourinary/Gynecological: Denies
tearing, itching, or blurry vision. Patient frequency, hesitancy, urgency, polyuria,
wearing glasses for vision correction. dysuria, hematuria, nocturia, incontinence,
stones, or infection. Denies vaginal pain, or
discharge
Ears: Denies hearing loss, tinnitus, vertigo, Hematologic/lymphatic/immunologic: Denies
discharge, or earache. any bruising/ bleeding tendency or frequent
infections.
Nose/Mouth/Throat: Denies rhinorrhea, Musculoskeletal: Denies muscle weakness,
stuffiness, sneezing, itching, allergy, pain, joint stiffness, ROM, instability, redness
epistaxis, bleeding gums, hoarseness, sore swelling arthritis, gout.
throat, swollen lymph nodes
Cardiovascular: Denies murmurs, angina, Neurological: Denies loss of sensation,
palpitations, dyspnea on exertion, orthopnea, tingling, tremors, weakness, fainting, or
PND, edema seizures. Denies impared memory, or difficulty
concentrating.
Respiratory: Denies shortness of breath, Psychiatric: Denies any changes in mood, sleep
wheezing, cough, sputum, hemoptysis, disturbances or psychiatric issues. DAST
pneumonia, asthma, bronchitis screening and PHQ-9 questionnaire reviewed
and documented.
Objective
Wt: 169f Temp: 98.7 Pulse: 80
Ht: 5ft 4in BP: 127/60 Oxygen sat: 100% Resp: 18
Physical Exam
This study source was downloaded by 100000900703063 from CourseHero.com on 02-09-2026 16:20:14 GMT -06:00
https://www.coursehero.com/file/76767770/Medicare-Wellness-Exam-SOAP-notedocx/
