HLT-308V Benchmark – Risk Management Program Analysis Part One and Two – Fall prevention strategy essay

May 30, | nursing, med, NURS, Paper

HLT-308V Benchmark – Risk Management Program Analysis Part One and Two – Fall prevention strategy essay
HLT-308V Benchmark – Risk Management Program Analysis Part One and Two – Fall prevention strategy essay
Risk Management Program Analysis
Introduction
Risks to patients, healthcare organizations, staff, and the community are prevalent within healthcare. Therefore, risk management in healthcare is very important in order to facilitate assessment, development, implementation, and monitoring of potential risks in order to prevent or minimize risk exposure (Simsekler et al, 2018). This paper will examine a risk management program with a safe patient environment and care, with a community focus. The selected risk management program is a fall prevention strategy in a community setting. HLT-308V Benchmark – Risk Management Program Analysis Part One and Two – Fall prevention strategy essay.
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Type of Risk Management Plan and Rationale
The risk management plan is fall prevention and reduction program targeting the geriatric population within a community setting. The plan focuses on identifying the individuals in the community at risk of falls and implementing appropriate providing evidence-based interventions. Prevention is the key step towards addressing fall reduction. The rationale for selecting fall prevention and reduction programs as a type of risk management plan is because falls pose major risks to the independence and health of the geriatric population (Ory et al., 2015). Falls are the leading cause of injuries among the geriatric population and they have significant adverse effects on the health and healthcare costs. The evidence further indicates that falls can be fatal especially in the geriatric population (Ory et al., 2015) HLT-308V Benchmark – Risk Management Program Analysis Part One and Two – Fall prevention strategy essay. Fortunately, falls are preventable and the selected program illustrates a fall prevention program that can be utilized within a community setting in order to minimize falls and assist the geriatric population to maintain their independence and health.
Standard Administrative Steps and Processes
The risk management process within the healthcare sector involves identifying the context; identification of risks; risk analysis; risks’ evaluation; and risks’ management. Identifying the context involves identifying the contextually high priority areas that need risk management in regard to patient care. The second step is to identify risks by becoming aware of the risks within the environment and healthcare services. Risk analysis follows by to comprehend the identified risks and this includes analyzing the intensity of the risks, primary causes and the available control actions against the identified risks (Jiménez-Rodríguez et al., 2018). After risk analysis, it is important to perform risk evaluation in order to prioritize risks basing on the severity of the risk as per the risk analysis score. Finally, risk management follows, where the appropriate measures are implemented in order to prevent and minimize the likelihood of the risk occurring (Lam et al., 2018).
The healthcare sector is a sector that impacts all individuals and hence the quality of care is an important marker of the health market competition. Therefore, there is a need to integrate an effective risk management procedure in healthcare organizations. Total Quality Management (TQM) is important in ensuring improved and better outcomes in the healthcare industry (Lam et al., 2018). The significance of integrating TQM programs such as risk management programs in healthcare organizations is to manage the likely risks that an organization can experience, thus lowering costs and improving customer satisfaction with the organization. The goal of risk management programs can be achieved by successfully fostering a culture that embraces risk management using evidence-based guidelines and evidence (Jiménez-Rodríguez et al., 2018).
In the identified risk management plan, the first step involved identifying the high priority in relation to patient care within the community setting and performing risk analysis. The older adults within the community were reporting high fall rates and hence falls were identified as a high priority area. Lack of available fall risk prevention programs was attributed to the high rate of falls in the community and thus fall prevention and reduction program was implemented.
Key Agencies and Organizations
Some of the key agencies with the responsibility to regulate the provision of safe care include Agency for Healthcare Research and Quality (AHRQ); Joint Commission on Accreditation of Health Care Organizations (JCAHO); National Committee for Quality Assurance (NCQA); Joint Commission; and Healthcare Quality Promotion (DHQP). AHRQ performs research aimed to improve the quality of health and improving patient safety while JCAHO focuses on ensuring that healthcare institutions provide quality care. NCQA works to ensure that the care plans meet the required quality standards while DHQP protects patients, protects healthcare providers, and promotes the quality care. The Joint commission focuses on the performance improvement measures that assist healthcare organizations to continuously enhance the quality of care and safety; this can lower the risk of low-quality care and medical errors (Allen-Duck et al., 2017).
Evaluation of the Compliance
The risk management program conforms to the requirement of the joint commission to continuously improve the safety and the quality of care; and the DHQP requirement to improve patient safety (Lam et al., 2018). The risk management program is a fall prevention program. The Joint Commission plays an essential role in helping healthcare institutions prevent falls and consequent injuries. The fall prevention program leads to raising awareness regarding the need to prevent falls; communicate safety information to the community and the health care providers; and integration of safety precautions in patient care and education. Fall reduction is the responsibility of everyone and as a result, the nursing staff, the community, physicians, quality and risk management, and physical and occupational therapy were actively involved during the designing of the fall prevention program (Phelan et al., 2015).
Generally, in compliance with the national and state polices and also compliance with the organizations that regulate patient safety, the program aimed to reduce falls and ensuing injuries by implementing various fall prevention measures (Allen-Duck et al., 2017).
Recommendations

Patient education on fall risk should be integrated into the program: The Joint Commission supports raising awareness about fall risk and using clinical champions to educate the relevant stakeholders about fall and the preventative strategies
The fall prevention program should adopt an interprofessional approach: According to the Joint Commission, an interprofessional team should be established in order to adopt a holistic approach towards fall prevention and reduction.
When identifying risk factors for falls in the community, standardized and validated tools should be used.
Post-Fall management should always be performed in order to inform improvement efforts and ensure the reevaluation of individuals sustaining falls (Phelan et al., 2015).

 
 
References
Allen-Duck, A., Robinson, J. C., & Stewart, M. W. (2017). Healthcare Quality: A Concept Analysis. Nursing Forum, 52(4), 377–386. doi:10.1111/nuf.12207.
Jiménez-Rodríguez, E., Feria-Domínguez, J. M., & Sebastián-Lacave, A. (2018). Assessing the Health-Care Risk: The Clinical-VaR, a Key Indicator for Sound Management. International journal of environmental research and public health, 15(4), 639. doi:10.3390/ijerph15040639.
Lam, M. B., Figueroa, J. F., Feyman, Y., Reimold, K. E., Orav, E. J., & Jha, A. K. (2018). Association between patient outcomes and accreditation in US hospitals: an observational study. BMJ (Clinical research ed.), 363, k4011. doi:10.1136/bmj.k4011.
Ory, M. G., Smith, M. L., Jiang, L., Lee, R., Chen, S., Wilson, A. D., … Parker, E. M. (2015). Fall prevention in community settings: results from implementing stepping on in three States. Frontiers in public health, 2(232). doi:10.3389/fpubh.2014.00232.
Phelan, E. A., Mahoney, J. E., Voit, J. C., & Stevens, J. A. (2015). Assessment and management of fall risk in primary care settings. The Medical clinics of North America, 99(2), 281–293. doi:10.1016/j.mcna.2014.11.004.
Simsekler, M., Ward, J. R., & Clarkson, P. J. (2018). Design for patient safety: a systems-based risk identification framework. Ergonomics, 61(8), 1046–1064. doi:10.1080/00140139.2018.1437224.
 

Benchmark – Risk Management Program Analysis – Part One

The purpose of this assignment is to analyze a health care risk management program.
Conduct research on approaches to risk management processes, policies, and concerns in your current or anticipated professional arena to find an example of a risk management plan. Look for a plan with sufficient content to be able to complete this assignment successfully. In a 1,000‐1,250-word paper, provide an analysis of the risk management plan that includes the following:

Summary of the type of risk management plan you selected (new employee, specific audience, community‐focused, etc.) and your rationale for selecting that example. Describe the health care organization to which the plan applies and the role risk management plays in that setting.
Description of the standard administrative steps and processes in a typical health care organization’s risk management program compared to the administrative steps and processes you identify in your selected example plan. (Note: For standard risk management policies and procedures, look up the MIPPA-approved accrediting body that regulates the risk management standards in your chosen health care sector, and consider federal, state, and local statutes as well.)
Analysis of the key agencies and organizations that regulate the administration of safe health care in your area of concentration and an evaluation of the roles each one plays in the risk management oversight process.
Evaluation of your selected risk management plan’s compliance with the standards of its corresponding MIPPA-approved accrediting body relevant to privacy, health care worker safety, and patient safety.
Proposed recommendations or changes you would implement in your risk management program example to enhance, improve, or secure the aforementioned compliance standards.

In addition to your textbook, you are required to support your analysis with a minimum of three peer‐reviewed references.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
 

Course Code
Class Code
Assignment Title
Total Points

HLT-308V
HLT-308V-O500
Benchmark – Risk Management Program Analysis – Part One
150.0

Criteria
Percentage
1: Unsatisfactory (0.00%)
2: Less Than Satisfactory (65.00%)
3: Satisfactory (75.00%)
4: Good (85.00%)
5: Excellent (100.00%)

% Scaling
100.0%

Summary Description of the Type of Risk Management Plan Selected With Rationale
15.0%
A summary description of the type of risk management plan selected, with rationale, is not included.
A summary description of the type of risk management plan selected, with rationale, is partially incorporated, but the information provided is incomplete, inaccurate, or otherwise deficient.
A summary description of the type of risk management plan selected, with rationale, is incorporated, but minimal detail or support is provided for one or more components.
A summary description of the type of risk management plan selected, with rationale, is incorporated in full. The submission encompasses essential details and provides appropriate support.
A summary description of the type of risk management plan selected with rationale is comprehensive. The submission incorporates specific examples with relevance and provides appropriate details.

Comparison of Standard Risk Management Program Administrative Steps and Processes With the Administrative Steps and Processes in the Example
15.0%
A comparison of standard risk management program administrative steps and processes with the administrative steps and processes in the example is not included.
A comparison of standard risk management program administrative steps and processes with the administrative steps and processes in the example is partially incorporated, but the information provided is incomplete, inaccurate, or otherwise deficient.
A comparison of standard risk management program administrative steps and processes with the administrative steps and processes in the example is incorporated, but minimal detail or support is provided for one or more components.
A comparison of standard risk management program administrative steps and processes with the administrative steps and processes in the example is incorporated in full. The submission encompasses essential details and provides appropriate support.
A comparison of standard risk management program administrative steps and processes with the administrative steps and processes in the example is comprehensive. The submission incorporates analysis of supporting evidence and provides specific examples with relevance. Level of detail is appropriate.

Analysis of Key Regulatory Agencies and Organizations Inclusive of Their Roles in the Risk Management Oversight Process
15.0%
An analysis of key regulatory agencies and organizations inclusive of their roles in the risk management oversight process is not included.
An analysis of key regulatory agencies and organizations inclusive of their roles in the risk management oversight process is partially incorporated, but the information provided is incomplete, inaccurate, or otherwise deficient.
An analysis of key regulatory agencies and organizations inclusive of their roles in the risk management oversight process is incorporated, but minimal detail or support is provided for one or more components.
An analysis of key regulatory agencies and organizations inclusive of their roles in the risk management oversight process is present and incorporated in full. The submission encompasses essential details and provides appropriate support.
An analysis of key regulatory agencies and organizations inclusive of their roles in the risk management oversight process is present and comprehensive. The submission incorporates analysis of supporting evidence and provides specific examples with relevance. Level of detail is appropriate.

Evaluation of the Example Risk Management Plan Compliance With MIPPA-Approved Accrediting Body Standards (C3.2)
15.0%
An evaluation of the example risk management plan compliance with the MIPPA-approved accrediting body standards is not included.
An evaluation of the example risk management plan compliance with the MIPPA-approved accrediting body standards is partially incorporated, but the information provided is incomplete, inaccurate, or otherwise deficient.
An evaluation of the example risk management plan compliance with the MIPPA-approved accrediting body standards is incorporated, but minimal detail or support is provided for one or more components.
An evaluation of the example risk management plan compliance with the MIPPA-approved accrediting body standards is present and incorporated in full. The submission encompasses essential details and provides appropriate support.
An evaluation of the example risk management plan compliance with the MIPPA-approved accrediting body standards is present and comprehensive. The submission incorporates analysis of supporting evidence and provides specific examples with relevance. Level of detail is appropriate.

Proposed Recommendations to the Risk Management Program Example to Enhance, Improve, or Secure Compliance Standards
15.0%
Proposed recommendations to the risk management program example to enhance, improve, or secure compliance standards are not included.
Proposed recommendations to the risk management program example to enhance, improve, or secure compliance standards are partially incorporated, but the information provided is incomplete, inaccurate, or otherwise deficient
Proposed recommendations to the risk management program example to enhance, improve, or secure compliance standards are incorporated, but minimal detail or support is provided for one or more components.
Proposed recommendations to the risk management program example to enhance, improve, or secure compliance standards are present and incorporated in full. The submission encompasses essential details and provides appropriate support.
Proposed recommendations to the risk management program example to enhance, improve, or secure compliance standards are present and comprehensive. The submission incorporates analysis of supporting evidence and provides specific examples with relevance. Level of detail is appropriate.

Thesis Development and Purpose
5.0%
Paper lacks any discernible overall purpose or organizing claim.
Thesis is insufficiently developed or vague. Purpose is not clear.
Thesis is apparent and appropriate to purpose.
Thesis is clear and forecasts the development of the paper. Thesis is descriptive and reflective of the arguments and appropriate to the purpose.
Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear.

Argument Logic and Construction
5.0%
Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses noncredible sources.
Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility.
Argument is orderly but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis.
Argument shows logical progression. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative.
Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative.

Mechanics of Writing (includes spelling, punctuation, grammar, language use)
5.0%
Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used.
Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied.
Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct and varied sentence structure and audience-appropriate language are employed.
Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech.
Writer is clearly in command of standard, written, academic English.

Paper Format (use of appropriate style for the major and assignment)
5.0%
Template is not used appropriately, or documentation format is rarely followed correctly.
Appropriate template is used, but some elements are missing or mistaken. A lack of control with formatting is apparent.
Appropriate template is used. Formatting is correct, although some minor errors may be present.
Appropriate template is fully used. There are virtually no errors in formatting style.
All format elements are correct.

Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style)
5.0%
Sources are not documented.
Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors.
Sources are documented, as appropriate to assignment and style, although some formatting errors may be present.
Sources are documented, as appropriate to assignment and style, and format is mostly correct.
Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error.

Total Weightage
100%

Benchmark – Risk Management Program Analysis – Part Two

The purpose of this assignment is to analyze how an organization’s quality and improvement processes contribute to its risk management program.
This assignment builds on the Risk Management Program Analysis – Part One assignment you completed in Topic 1 of this course.
Assume that the sample risk management program you analyzed in Topic 1 was implemented and is now currently in use by your health care employer/organization. Further assume that your supervisor has asked you to create a high‐level summary brief of this new risk management program to share with a group of administrative personnel from a newly created community health organization in your state who has enlisted your organization’s assistance in developing their own risk management policies and procedures.
Compose a 1,250‐1,500 word summary brief that expands upon the elements you first addressed in the Topic 1 assignment. In this summary brief, address the following points regarding your health care organization and its risk management program:

Explain the role of your organization’s MIPPA-approved accreditation body (e.g., JC, ACR, IAC) in the evaluation of your institution’s quality improvement and risk management processes.
Describe the roles that different levels of administrative personnel play in healthcare ethics and establishing or sustaining employer/employee-focused organizational risk management strategies and operational policies.
Illustrate how your organization’s risk management and compliance programs support ethical standards, patient consent, and patient rights and responsibilities.
Explain the legal and ethical responsibilities health care professionals face in upholding risk management policies and administering safe health care at your organization.
Relate how your organization’s quality improvement processes support and contribute to its overall journey to excellence.

In addition to your textbook, you are required to support your analysis with a minimum of three peer‐reviewed references.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required. HLT-308V Benchmark – Risk Management Program Analysis Part One and Two – Fall prevention strategy essay
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
 
 

Course Code
Class Code
Assignment Title
Total Points

HLT-308V
HLT-308V-O500
Benchmark – Risk Management Program Analysis – Part Two
150.0

Criteria
Percentage
1: Unsatisfactory (0.00%)
2: Less Than Satisfactory (65.00%)
3: Satisfactory (75.00%)
4: Good (85.00%)
5: Excellent (100.00%)

% Scaling
100.0%

Role of the MIPPA-Approved Accreditation Body in Evaluation of the Quality Improvement and Risk Management Processes of an Organization
15.0%
An explanation of the role that the MIPPA-approved accreditation body plays in the evaluation of the quality improvement and risk management processes of an organization is not included. HLT-308V Benchmark – Risk Management Program Analysis Part One and Two – Fall prevention strategy essay
An explanation of the role that the MIPPA-approved accreditation body plays in the evaluation of the quality improvement and risk management processes of an organization is incomplete, inaccurate, or otherwise deficient.
An explanation of the role that the MIPPA-approved accreditation body plays in the evaluation of the quality improvement and risk management processes of an organization is incorporated, but minimal detail or support is provided for one or more components.
An explanation of the role that the MIPPA-approved accreditation body plays in the evaluation of the quality improvement and risk management processes of an organization is present and incorporated in full. The submission encompasses essential details and provides appropriate support.
An explanation of the role that the MIPPA-approved accreditation body plays in the evaluation of the quality improvement and risk management processes of an organization is comprehensive. The submission further incorporates analysis of supporting evidence insightfully and provides specific examples with relevance. Level of detail is appropriate.

Administrative Roles Relevant to Employer-Employee-Focused Risk Management Strategies and Operational Policies
15.0%
A description of the roles administrative personnel play relevant to employer-employee-focused risk management strategies and operational policies is not included.
A description of the roles administrative personnel play relevant to employer-employee-focused risk management strategies and operational policies is partially incorporated, but the information provided is incomplete, inaccurate, or otherwise deficient.
A description of the roles administrative personnel play relevant to employer-employee-focused risk management strategies and operational policies is incorporated, but minimal detail or support is provided for one or more components.
A description of the roles administrative personnel play relevant to employer-employee-focused risk management strategies and operational policies is incorporated in full. The submission encompasses essential details and provides appropriate support.
A description of the roles administrative personnel play relevant to employer-employee-focused risk management strategies and operational policies is comprehensive. The submission incorporates analysis of supporting evidence insightfully and provides specific examples with relevance. Level of detail is appropriate.

Support of Patient Rights and Responsibilities by Risk Management Programs and Quality Improvement Processes
15.0%
An illustration of how the rights and responsibilities of a patient are supported by risk management programs and quality improvement processes is not included.
An illustration of how the rights and responsibilities of a patient are supported by risk management programs and quality improvement processes is partially incorporated, but the information provided is incomplete, inaccurate, or otherwise deficient.
An illustration of how the rights and responsibilities of a patient are supported by risk management programs and quality improvement processes is incorporated, but minimal detail or support is provided for one or more components.
An illustration of how the rights and responsibilities of a patient are supported by risk management programs and quality improvement processes is incorporated in full. The submission encompasses essential details and provides appropriate support.
An illustration of how the rights and responsibilities of a patient are supported by risk management programs and quality improvement processes is comprehensive. The submission incorporates analysis of supporting evidence insightfully and provides specific examples with relevance. Level of detail is appropriate.

Legal and Ethical Responsibilities of Health Care Professionals to Uphold Risk Management Policies and Administer Safe Health Care (C3.3)
HLT-308V Benchmark – Risk Management Program Analysis Part One and Two – Fall prevention strategy essay
15.0%
An explanation of the legal and ethical responsibilities of health care professionals to uphold risk management policies and administer safe health care is not included.
An explanation of the legal and ethical responsibilities of health care professionals to uphold risk management policies and administer safe health care is partially incorporated, but the information provided is incomplete, inaccurate, or otherwise deficient.
An explanation of the legal and ethical responsibilities of health care professionals to uphold risk management policies and administer safe health care is incorporated, but minimal detail or support is provided for one or more components.
An explanation of the legal and ethical responsibilities of health care professionals to uphold risk management policies and administer safe health care is incorporated in full. The submission encompasses essential details and provides appropriate support.
An explanation of the legal and ethical responsibilities of health care professionals to uphold risk management policies and administer safe health care is comprehensive. The submission incorporates analysis of supporting evidence insightfully and provides specific examples with relevance. Level of detail is appropriate.

How Quality Improvement Processes in a Health Care Organization Support Its Journey to Excellence
15.0%
Evidence of how the quality improvement processes of a health care organization support its journey to excellence is not included.
Evidence of how the quality improvement processes of a health care organization support its Journey to Excellence is incomplete, inaccurate, or otherwise deficient.
Evidence of how the quality improvement processes of a health care organization support its Journey to Excellence is incorporated, but minimal detail or support is provided for one or more components.
Evidence of how the quality improvement processes of a health care organization support its Journey to Excellence is incorporated in full. The submission encompasses essential details and provides appropriate support.
Evidence of how the quality improvement processes of a health care organization support its Journey to Excellence is comprehensive. The submission further incorporates analysis of supporting evidence insightfully and provides specific examples with relevance. Level of detail is appropriate.

Thesis Development and Purpose
5.0%
Paper lacks any discernible overall purpose or organizing claim.
Thesis is insufficiently developed or vague. Purpose is not clear.
Thesis is apparent and appropriate to purpose.
Thesis is clear and forecasts the development of the paper. Thesis is descriptive and reflective of the arguments and appropriate to the purpose.
Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear.

Argument Logic and Construction
5.0%
Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses noncredible sources.
Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility.
Argument is orderly but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis.
Argument shows logical progression. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative.
Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative.

Mechanics of Writing (includes spelling, punctuation, grammar, language use)
5.0%
Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used.
Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied.
Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct and varied sentence structure and audience-appropriate language are employed.
Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech.
Writer is clearly in command of standard, written, academic English.

Paper Format (use of appropriate style for the major and assignment)
5.0%
Template is not used app

Lower back pain soap note examples

May 30, | nursing, med, NURS, Paper

Lower back pain soap note examples
Lower back pain soap note examples
CC: lower back pain x 1 week
 
HPI: 42-year-old obese female presents with complaints of lower back pain for the past week that feels worse today. The pain is constant and intermittently radiates down her left leg. It is not improved with ibuprofen. She works as a grocery store clerk.
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Review of systems:
General: No fever, chills, or weight changes or sweating or general weakness.
Eyes: No blurred or double vision or pain or redness.
Ears: No pain or decrease in hearing.
Nose: No runny nose or blockage or bleeding.
Throat: No sore throat.
Head: No headache.
Chest: No chest pain or cough or shortness of breath or wheezing.
Breasts: No pain or tenderness or noticeable lump.
Heart: No irregular heart beat or palpitations or chest pain.
Gastrointestinal: No nausea or vomiting or constipation or difficulty swallowing or rectal bleeding or bloating or distension or hemorrhoids or diarrhea or abdominal discomfort.
Genitourinary: No vaginal discharge or bleeding or dysuria or vaginal problems.
Musculoskeletal: No muscle problems or weakness. Lower back pain that radiates down left leg.
Skin: No rashes or bruises or skin masses or other skin complaints.
Neurologic: No weakness or headache or seizures or numbness or tingling.
Psychiatric: No anxiety or depression or suicidal/homicidal thoughts.
Endocrine: No excessive thirst or excessive urination or excessive heat or cold.
Immunologic: No tuberculosis or hepatitis or HIV or recurrent infections.
Hematologic: No anemia or easy bruising or bleeding.
Lower back pain soap note examples
 
PMHx: none
FamilyHx: none
SocialHx: Pt works as a grocery store clerk
Allergies: NKA
Objective:
66 in
275 lb
44.4
122/75 mmHg
78 bpm
14 bpm
97.6 °F
99 %
 
General: Normotensive, in no acute distress.
Head: Normocephalic, no lesions.
Eyes: PERRLA, EOM’s full, conjunctivae clear, fundi grossly normal.
Ears: EAC’s clear, TM’s normal.
Nose: Mucosa normal, no obstruction.
Throat: Clear, no exudates, no lesions.
Neck: Supple, no masses, no thyromegaly, no bruits.
Chest: Lungs clear, no rales, no rhonchi, no wheezes.
Heart: RR, no murmurs, no rubs, no gallops.
Abdomen: Soft, no tenderness, no masses, BS normal.
Back: Normal curvature, no tenderness.
Extremities: FROM, no deformities, no edema, no erythema.
Neuro: Physiological, no localizing findings.
Skin: Normal, no rashes, no lesions noted.
Lower back pain soap note examples
ORDER A PLAGIARISM-FREE PAPER HERE
Assessment:
Actual Dx:

(E66.0) Obesity, body mass index (bmi 40-44.9).

(M54.5) Dorsalgia, acute low back pain.

ICD-10-CM Codes. (2019). Retrieved from https://www.icd10data.com/ICD10CM/Codes/
Plan:
– begin medications listed below as needed.
– pt educated on importance of weight loss and dietary modification to reduce back strain
– RTC for follow up in 30 days if symptoms persist

Ultram (tramadol) 100 MG Oral Tablet Sig: Take 1 tablet (100 mg) by mouth every 6 hours as needed for pain. #40, no refills.
Flexeril (cyclobenzaprine) 10 MG Oral Tablet Sig: Take 1 tablet (10 mg) by mouth every 8 hours as needed. Take at bedtime if drowsiness occurs. #30, no refills.

Ultram, Flexeril: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing. (2019). Retrieved from https://www.webmd.com/drugs
Education:
Provide education to pt on importance of dietary modification and exercise in order to lose weight and reduce strain on her back. Stress importance of establishing goals and the health benefits associated with a healthy BMI. If necessary and pt continues to struggle in 30 days will refer to dietician for additional support on nutrition and increasing her level of physical activity (UpToDate, 2019).
 
History & Physical Examination
 
Patient Demographics:
Name: T.H.
Age/race/sex: 26 Hispanic Female
Clinical site: Primary Care clinic; Presents for sick visit.
 
 
SUBJECTIVE DATA
 
Chief Complaints:     “My lower back has been hurting for about 2 weeks now”.
 
History of Present Illness:  
Mrs. H is a 26 y/o Hispanic female with a six year history of depression-controlled on Sertraline, who presents to the clinic today complaining of spontaneous occurring acute low back pain to lumber region that started about 2 weeks ago after wearing heels to a party. Reports it has been very difficult to dress lower body and to bend. She reports the pain is constant but has intermittent intensities of aching and soreness throughout the day. The pain is localized to the lumber area, described as aching and soreness with no radiation, rated a 5/10 in office today with 3/10 being the lowest amount of pain experienced and 8/10 being the worst pain she has experienced. Reports the pain is worse in the mornings when getting out of bed after lying down all night. She hasn’t tried any pharmacological or non-pharmacological therapies. She reports no heavy lifting, strenuous exercise, current injuries, nor feelings of anxiety or depression. However, about 5 years ago she was riding her bike, went down a ramp and flipped head first over the handle bars of the bike. At which time she experienced this same low back pain, went to the ER and had X-rays that showed some inflammation and swelling. She was then prescribed a muscle relaxant, Ibuprofen, and physical therapy for 8 weeks, which helped tremendously. At today’s visit, she hopes to find out where the pain is coming from and what she can do to prevent it from returning. Lower back pain soap note examples
 
Past Medical History:

Depression-active- diagnosed 6 years ago after mom passed in a MVA
Low back pain-active-diagnosed about 5 years ago after previous back injury.

 
 
Past Surgical History:

No surgeries to date

 
Allergies:
NKA to food, dust, mold, environment, or medications.
 
Medications:
Sertraline 150 mg by mouth daily for depression
 
Health Maintenance:

Influenza Vaccine-October 2017 at CVS.
All other immunizations are up-to-date including TDaP, MMR, and Varicella.
Last Pap smear- June 2016-normal
Performs MSBE
Depression screen positive for PHQ2; on meds and see Psychologists regularly.
CAGE 0/4

 
Personal & Social History:

Lives alone in a one bedroom apartment.
Works at a nursing home as a Certified Nursing Assistant 4 days/week. She loves her job and has a dependable car.
Denies any smoking, illicit drug abuse, or alcohol misuse.
Previously did cross fit in high school. However, do to work she hasn’t had much time to get the amount of exercise she needs.
Patient is sexually active with only one sex partner, her boyfriend.
24 hour diet recall: B- one bowl of Chex cereal; L- a turkey sandwich, chips, and a diet coke; S-about 1-2 cups of cheese-it crackers and a diet coke; D- Meatloaf, veggies, mashed potatoes from Boston Market, and a bottled water. Lower back pain soap note examples

 
Family History:
Grandparents
Paternal:      Paternal grandfather 81, HTN, DM; Paternal grandmother 76 history of DM
and MI.
Maternal:     Maternal grandfather died at 82 from MI, maternal grandmother 79, history
of diabetes and arthritis.
 
Parents
Father:         Father 59, history of HTN, Diabetes, Depression, and Stroke.
Mother:        Mother 52, died in a MVA.
 
Siblings
Siblings:      Only child.
 
Children
Children:     No children.
 
Review of Systems:  

General
Denies any fever, chills, night sweats, weight loss or weight gain in the past year.

Skin
Denies dry skin and itching. Denies abnormal lesions or new nevi/moles

Head
Previous head injury, denies any masses, lesions and headache

Eyes
Denies any discharge, itchy, blurred vision, vision loss or vision changes, eye pain or injection.

Ears
Denies any itching, fullness, vertigo, ear pain or drainage, hearing loss or changes in quality of hearing.

Nose/Sinuses
Denies epistaxis, PND, maxillary or frontal sinus pain, or changes in smell

Mouth/Throat
Denies sore throat and dysphagia. Denies gum disease, has all original teeth, last dental exam was in July of this year, sees the dentist annually.

Neck/Lymph Nodes
Denies swollen /painful lymph nodes, denies any neck pain or stiffness. Lower back pain soap note examples

Breasts
Denies masses, pain, or nipple discharge. Does perform regular SBE.

Thorax/Respiratory
Denies any SOB, DOE, or wheezing.

CVS
Denies CP, palpitations, denies peripheral edema, Orthopnea

GI/Abdomen
Denies dyspepsia, nausea, vomiting, diarrhea, constipation, bloating, hematemesis, hematochezia, or abdominal pain. No recent changes in bowel habits. Last bowel movement was this morning, which is consistent with her regular bowel habits and was normal.

GU
Denies any pain on urination, frequency, urgency, or vaginal discharge.

Musculoskeletal
See HPI.

Neurologic
Denies memory loss, numbness, tingling, or burning pains or weakness.

Endocrine
Denies known glucose abnormalities, heat or cold intolerance

Psychiatric
Reports a history of depression but denies any anxiety.

 
 
OBJECTIVE
Physical Examination:

Vital Signs/HT/WT
T: 98.2F, P: 72 readily palpable, RR: 16, BP 110/64 on right, 110/68 on the left SaO2 on RA: 100% HT: 5’8”, WT: 128lbs (toned-physique, stable with no gains or losses within the last 6 months), BMI: 19.46, normal for ht. and wt.

General
26 y/o Hispanic female, pleasant appears her stated age sitting on the examination table in moderate distress as evidenced by arms tensed on elbows as she’s guarding pain. Well groomed, well developed, AAOx3

Skin
Warm, moist, no rashes or suspicious moles, +turgor

Head/Scalp
ATNC, thick black hair, no dandruff, no lesions/masses.

Eyes
External examination without ptosis, strabismus or exophthalmos. Conjunctiva pink. Rest of exam deferred.

Ears
Auricles symmetrical, no lesions or tophi; Rest of exam deferred.

Nose
Bilateral nasal turbinates’ pink, moist. Rest of exam deferred.

Sinuses
Deferred

Mouth
Lips pink, moist mucous membrane, tongue protrudes in midline.

Pharynx/Throat
Deferred. Lower back pain soap note examples

Neck/Lymph nodes
Trachea midline with full AROM without pain.

CVS
RRR, normal S1, S2, no murmurs, rubs, or extra systole, JVD 3cm at 30 degrees, no carotid bruits, no cyanosis or vascular lesions. No chest wall deformity. PMI at 5th ICM MCL. Non-tender without heaves or thrill. Auscultation of the abdomen without bruit. Palpation without pulsatile masses

Lungs/Thorax
Chest symmetrical without deformity, respirations even and unlabored throughout anterior and posterior lung fields. Palpation without tenderness.  Tactile fremitus present. Resonance heard on percussion throughout anterior and posterior lung fields. Vesicular breath sounds auscultated throughout anterior and posterior peripheral lung fields.

Breasts
Deferred

Abdomen
Deferred

GU
Deferred

Musculoskeletal
Mandible moves in midline TMJ palpation without clicks or tenderness. Neck and cervical spine have no noted deformities or signs of inflammation. Curvature of cervical, thoracic and lumbar spine within normal limits. Bony features of shoulders and hips are of equal height bilaterally and non-tender. Posture is slumped and gait is smooth but guarded. Palpation of spinous processes of C7-L5 are palpable, midline, and tender to deep palpation right below L5. Discomfort noted with lying flat on exam table. Patient can bend to touch toes but experiences discomfort at about 90 degrees from the upright position. Although patient can actively perform such maneuvers as bending her knees to her chest while lying flat, flex, extend, and rotate the spine there is some mild discomfort and pain noted throughout the maneuvers.

Extremities/Pulses
No edema, erythema or cyanosis to upper or lower extremities. Pulses 2/4 to bilateral femoral, popliteal, posterior tibial, and dorsalis pedis pulses.

Neurologic
AA O X3. Slumped posture while sitting and walking. Gait steady and intact. Sensation intact to light, deep, and sharp touch. gait and balance intact. CN II- XII intact.  Memory and cognition intact for present and past medical history.

Psych
Appropriate mood and affect

 
Evidence Based Assessment/Plan
Clinical Decision Making:  26 y/o Hispanic female presents to the primary care clinic with a two week history of constant low back pain worse when ambulating and dressing. The pain is non-radiating and has intermittent intensities of aching and soreness consistent with acute non-specific low back pain. She has experienced these symptoms before after a biking accident 5 years ago. Given Mrs. H’s presenting signs and symptoms there is a need to differentiate between the diagnosis of acute non-specific low back pain and low back pain with radiculopathy. Mrs. H is an otherwise healthy young female with a history of depression controlled on antidepressant. She has no other co-morbidities or health issues.
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Differential Diagnosis:

CHARACTERISTICS OF DIFFERENTIAL DIAGNOSIS
SIGNS AND SYMPTOMS
PHYSICAL EXAM FINDINGS

Non-specific Acute Low Back Pain
Nonspecific or nonradicular low back pain is not associated with neurologic symptoms or signs. In general, the pain is localized to the spine or paraspinal regions (or both) and does not radiate into the leg. In general, nonspecific low back pain is not associated with spinal nerve root compression. Nonspecific low back pain might or might not be associated with significant pathology on magnetic resonance imaging (MRI) and is often a result of simple soft tissue disorders such as strain, but it can also be caused by serious medical disorders arising in the bony spine, parameningeal, or retroperitoneal regions.
 
Risk factors:
Smoking, obesity, older age, female gender, physically strenuous work, sedentary work, a stressful job, job dissatisfaction and psychological factors such as anxiety or depression.
 
Diagnosis:
Diagnosis is based on physical exam findings. Routine spine radiographs are of limited value because they visualize only bony structures. Guidelines from the U.S. Agency for Health Care Policy and Research (AHCPR) indicated value of routine spine radiographs for acute low back pain in the following settings: acute major trauma, minor trauma associated with risk of osteoporosis, risk of spinal infection, pain that does not respond to rest or recumbency, and history of cancer, fever, or unexplained weight loss. They may also be of value in assessing spinal alignment and rheumatologic disorders of bone. The American Academy of Neurology guideline recommends nonsurgical therapy before CT and MRI are used in patients with uncomplicated acute low back pain of less than 7 weeks’ duration.
www.aafp.org
 
Pain areas: in the low back, muscles and bones, hip, or leg.
 
Sensory: leg numbness or pins and needles.
 
Back joint dysfunction or muscle spasms.
 
Slumped gait due to pain on standing upright.
 
 
 
 
 
 
 
 
Some physical exam findings of low back pain may include the following;
 
Superficial tenderness over the lumbar region to light touch
 
Nonanatomic tenderness
 
Exacerbation of pain by applying a few pounds of pressure with the hands to the top of the head
 
Exacerbation of pain by simulated rotation or flexion of the spine
 
Ability to sit up straight from a supine position, but intolerance of the straight-leg-raising test
 
Nonanatomic distribution of sensory changes
 
http://www.clevelandclinicmeded.com
 

Acute lumbosacral radiculopathy
Low back pain accompanied by spinal nerve root damage is usually associated with neurologic signs or symptoms and is described as radiculopathy. There is usually pathologic evidence of spinal nerve root compression by disk or arthritic spur, but other intraspinal pathologies may be present and are often apparent on an MRI scan of the lumbosacral spine.
Risk factors:
Traumatic injury
Lumbar sprain or strain
Postural strain
sitting, standing or walking >2hrs per day
frequent moving or lifting >25 lbs.
strength <50% depression obesity poor health prior LBP poor back endurance Osteoarthritis Rheumatoid Arthritis www.aafp.org Diagnosis: After the initial examination, the diagnosis of lumbar radiculopathy can be supported by electrodiagnosis, MRI, CT scans, and/or contrast myelography. Treatment of lumbar radiculopathy will vary depending on the actual cause of the radiculopathy. These treatments can include the use of back supports, medication, physical therapy, steroid injection in the spine, and even surgery. http://www.aanem.org   Radiculopathy — A common feature of low back pain is radiculopathy, which occurs when a nerve root is irritated by a protruding disc or arthritis of the spine. Radiculopathies usually cause radiating pain, numbness, tingling, or muscle weakness in the specific areas related to the affected nerve root, usually the lower leg. Most people with these conditions improve with limited or no treatment, described below. Lower back pain soap note examples Sciatica — Sciatica refers to the most common symptom of radiculopathy. It is a pain that occurs when one of the five spinal nerve roots, which are branches of the sciatic nerve, is irritated, causing a sharp or burning pain that extends down the back or side of the thigh, usually to the foot or ankle. You may also feel numbness or tingling. Occasionally, the sciatica may also be associated with muscle weakness in the leg or the foot. If a disc is herniated, sciatic pain often increases with coughing, sneezing, or bearing down. Neurogenic claudication — Neurogenic claudication is a type of pain that can occur when the spinal cord is compressed due to narrowing of the spinal canal from arthritis or other causes. The pain runs down the back to the buttocks, thighs, and lower legs, often involving both sides of the body. This may cause limping and weakness in the legs. Pain usually gets worse when extending the lower spine (e.g., when standing or walking), and gets better when flexing the spine by sitting, stooping, or leaning forward.   The onset of symptoms in patients with lumbosacral radiculopathy is often sudden and includes LBP. Some patients state the preexisting back pain disappears when the leg pain begins. Sitting, coughing, or sneezing may exacerbate the pain, which travels from the buttock down to the posterior or posterolateral leg to the ankle or foot. Radiculopathy in roots L1-L3 refers pain to the anterior aspect of the thigh and typically does not radiate below the knee, but these levels are affected in only 5% of all disc herniations. When obtaining a patient’s history, be alert for any red flags (i.e., indicators of medical conditions that usually do not resolve on their own without management). Such red flags may imply a more complicated condition that requires further workup (e.g., tumor, infection). The presence of fever, weight loss, or chills requires a thorough evaluation. Patient age is also a factor when looking for other possible causes of the patient’s symptoms. Individuals younger than 20 years and those older than 50 years are at increased risk for more malignant causes of pain (e.g., tumor, infection).   POC LABS to Review No POC labs to review   Diagnosis 1-Guidelines for Treatment for Non-Specific Acute Low Back Pain (most likely dx): There is general agreement that patients with acute nonspecific spine pain or nonlocalizable lumbosacral radiculopathy (without neurologic signs or significant neurologic symptoms) require only conservative medical management. Patients should abstain from heavy lifting or other activities that aggravate the pain. Bed rest is not helpful and has been shown to delay recovery. Bed rest may be recommended for the first few days for patients with severe pain with movement. Recommended medications include nonsteroidal anti-inflammatory drugs such as ibuprofen or aspirin. If there are complaints of muscle spasm, muscle relaxants such as cyclobenzaprine may be used in the acute phase of pain. Narcotic analgesia should be avoided, in general, but it can be prescribed in cases of severe acute pain. A study by Cherkin and coworkers compared standard physical therapy maneuvers and chiropractic spinal manipulation for the treatment of acute low back pain and found that both provide small short-term benefits and improve patient satisfaction. Nonpharmacologic treatment, including superficial heat, massage, acupuncture, or spinal manipulation, should be used initially for most patients with acute or sub-acute low back pain, as they will improve over time regardless of treatment. When pharmacologic treatment is desired, nonsteroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants should be used. Avoid imaging in cases of uncomplicated low back pain (unless there are specific clinical indications). Medications prescribed today;   Diclofenac Sodium 50 mg 1 by mouth twice daily for pain for 2 weeks. Flexeril (Cyclobenzaprine) 10 mg 1 tab by mouth three times a day as needed for muscle spasms for 2 weeks. www.aafp.org   Diagnostic test needed: No further diagnostic test needed at this time. Diagnosis was based on clinical presentation, history, and physical exam.   Referrals/Consults: Referral for physical therapy to evaluate and treat for low back pain and spasms.   Patient Education: Remaining active — many people are afraid that they will hurt their backs further or delay recovery by remaining active. However, remaining active is one of the best things you can do for your back. In fact, prolonged bed rest is not recommended. Studies have shown that people with low back pain recover faster when they remain active. Movement helps to relieve muscle spasms and prevents loss of muscle strength. Although high-impact activities should be avoided, it is fine to continue doing regular day-to-day activities and light exercises, such as walking. If certain activities cause the back to hurt too much, it is fine to stop that activity and try another. If back pain is severe, bedrest may be necessary for a short period of time, generally no more than one day. When in bed, the most comfortable position may be to lie on the back with a pillow behind the knees and the head and shoulders elevated, or to lie on the side with the upper knee bent and a pillow between the knees.   Heat — using a heating pad can help with low back pain during the first few weeks. It is not clear if cold packs help as well.   Work — most experts recommend that people with low back pain continue to work so long as it is possible to avoid prolonged standing or sitting, heavy lifting, and twisting. Some people need to stay home from work if their occupation does not allow them to sit or stand comfortably. While standing at work, stepping on a block of wood with one foot (and periodically alternating the foot on the block) may be helpful. Pain medications — Take medications on a regular basis for two weeks for it to be effective, rather than using the medication only when the pain becomes unbearable. If needed, take muscle relaxant before bedtime. Do not take this medication while driving or operating machinery.   Exercise — a program of exercises can help to increase back flexibility and strengthen the muscles that support the back. Although starting back exercises or stretching immediately after a new episode of low back pain might temporarily increase the pain, the exercise may reduce the total duration of pain and prevent recurrent episodes. Lower back pain soap note examples Recommended activities include those that involve strengthening and stretching, such as walking, swimming, use of a stationary bicycle, and low-impact aerobics. Avoid activities that involve twisting, bending, are high-impact, or make the back hurt more. Some specific exercises may help strengthen the muscles of the lower back. People with frequent episodes of low back pain should continue these exercises indefinitely to prevent new episodes.   Mattress choice – The benefit of a firm mattress in preventing or treating low back pain has not been proven. In one study, medium-firm mattresses were more likely to improve chronic back pain compared with firm mattresses https://www.uptodate.com/contents/low-back-pain-in-adults   Diagnosis 2-Guidelines for Treatment for Acute Lumbosacral Radiculopathy: The initial treatment of the patient with lumbosacral radiculopathy presenting with sensory symptoms and pain without significant neurologic deficits is not different from the approach for the patient with uncomplicated low back pain. However, such patients require observation for possible worsening of their neurologic status. For patients with acute lumbosacral radiculopathy, the objectives of treatment are to ameliorate pain (symptomatic treatment) and to address the specific underlying process (mechanism-specific treatment) if necessary http://www.clevelandclinicmeded.com   Diagnostic test needed: If signs and symptoms of radiculopathy, sciatica, or neurogenic claudication exists the patient may require one or more of test including Spinal Radiography, CT scan, MRI, contrast myelography, or electrodiagnosis. http://www.aanem.org   Referrals/Consults: Referral to an orthopedic surgeon or neurosurgeon is recommended under the following circumstances: Increasing neurologic problems (measurable weakness) Loss of sensation (e.g., numbness) or bladder and bowel symptoms Failure to improve after four to six weeks of nonsurgical management, with persistent and severe sciatica and evidence of nerve root involvement https://www.uptodate.com/contents/low-back-pain-in-adults   Patient Education: Most people with radiculopathy improve with conservative treatment such as medication and PT. Surgery is recommended for some people with radiculopathy. They, too, usually improve after a recovery period. Following treatment, most people are able to work and take part in other daily activities. Patient education would include education to prevent acute non-specific low back pain in addition to reducing chances of developing radiculopathy by maintaining good posture and a healthy weight. Using safe techniques when lifting heavy objects to prevent injuries to your back. Remembering to lift with your knees. That means you should bend your knees, not your back. Also asking for help when moving heavy or bulky objects and when doing repetitive tasks, take frequent breaks. https://www.healthline.com   Prevention: There are a number of ways to prevent low back pain from returning. Perhaps the most important are exercise and staying active. Regular exercise that improves cardiovascular fitness can be combined with specific exercises to strengthen the muscles of the hips and torso. The abdominal muscles are particularly important in supporting the lower back and preventing back pain. It is also important to avoid activities that involve repetitive bending or twisting and high-impact activities that increase stress in the spine.   Bend and lift correctly — People with low back pain should learn the right way to bend and lift. As an example, lifting should always be done with the knees bent and the abdominal muscles tightened to avoid straining the weaker muscles in the lower back (p   Take a break — People who sit or stand for long periods should change positions often and use a chair with appropriate support for the back. An office chair should be readjusted several times throughout the day to avoid sitting in the same position. Taking brief but frequent breaks to walk around will also prevent pain due to prolonged sitting or standing. People who stand in place for long periods can try placing a block of wood on the floor, stepping up and down every few minutes. https://www.uptodate.com/contents/low-back-pain-in-adults   Healthcare Maintenance/Recommendations:   Annual Influenza vaccine education provided-Received in October of 2017 Depression screen-positive- Recommended to continue Sertraline and visits to Psychologists as scheduled. CAGE-0/4 STI and STD education Sex behavioral counseling Reinforced recommendations for MSBE Cervical Cancer screen and HPV education-Recommended continuing routine Pap testing every 3 years. Diet and exercise education- Recommended to exercise at least 3 days/week; with exercises to help strengthen the core muscles. Continue eating a healthy diet and stay hydrated during workouts. Recommended using a back brace while at work to help with support with lifting and to call for lifting help instead of trying lift alone.   The USPSTF also recommends high blood pressure, depression, and alcohol misuse screening in this age group. Screening for HIV, Syphilis, HBV, HCV, and STI screening and behavioral counseling is also recommended in all sexually active females in this age group. Although, Mrs. H has a toned physique I think it’s important to counsel her on the importance of daily exercise and physical activity to help reduce pain and on healthful diet practices such as the DASH diet, which is high in grains, fruits, vegetables, and low in fat to help prevent future co-morbidities especially since her family history is so significant for such severe co-morbidities and mortalities.   Follow-up: Follow up in 2 weeks for evaluation of pain management or as needed if pain becomes worse or changes in presentation.     References American Academy of Family Physicians. (2017). Diagnosis and Treatment of Low Back Pain; Clinical Practice Guidelines. Retrieved from: http://www.aafp.org/patient-care/clinical-recommendations/all/back-pain.html American Association of Neuromuscular & Electrodiagnostic Medicine. (2017). Lumbar Radiculopathy. Retrieved from: http:www.aanem.org/Patients/Disorders/Lumbar-Radiculopathy Cleveland Clinic Center for Center for Continuing Education. Published by; Levin, Kerry. M.D. (2010). Low Back Pain. Retrieved from: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/neurology/low-back-pain/#top Healthline. (2017). Radiculopathy (Pinched Nerve). Retrieved from: https://www.healthline.com/health/radiculopathy#overview1 Lower back pain soap note examples Scientific Electronic Library Online by Ladeira, Carlos (2011). Evidence based practice guidelines for management of low back pain: physical therapy implications. Retrieved from: http://www.scielo.br/pdf/rbfis/v15n3/04.pdf U.S. Preventive Services Task Force. (2017). Grade A and B Recommendations. https://www.uspreventiveservicestaskforce.org/Search UpToDate. (2017). Patient Education. Low Back Pain in Adults (Beyond the Basics). Retrieved from: https://www.uptodate.com/contents/low-back-pain-in-adults-beyond-the-basics Lower back pain soap note examples