Podiatry Progress Note Templates with ExamplesUpdated: November 20, 2023
The diagnosis, treatment, and prevention of conditions of the foot and ankle, necessitates maintaining detailed patient records. Having clear and organized notes helps streamline patient care and ensure that all relevant clinical information is readily available for subsequent appointments or for other healthcare providers.
In this article, we will explore two popular note structures used in podiatry: the General Podiatry Note and the Podiatry SOAP Note.
Components of a Podiatry Note
Before diving into the specific templates, it’s important to understand the essential components that make up a comprehensive podiatry note. Here, we’ll break down the elements that are included in both general and SOAP notes.
General Podiatry Note
- Patient Details: This section captures the basic identifying details of the patient. It usually includes the full name, age, gender, and contact information, ensuring that the note is correctly associated with a specific individual.
- Date of Visit: It is crucial to document the date of the patient’s visit to track progression, healing, and the timing of interventions.
- Presenting Complaint: A concise statement that captures the primary reason for the visit. This gives a snapshot of the patient’s main issue.
- History of Present Illness: An in-depth account of the symptoms. This traces the onset, duration, aggravating and relieving factors, and any other relevant symptom details.
- Past Medical History: Background information on a patient’s health, like previous conditions, surgeries, medications, and allergies, can provide context and influence treatment decisions.
- Physical Examination: A record of the clinical findings when examining the foot and ankle. This might include observations on swelling, discoloration, deformities, etc.
- Diagnosis: Based on the gathered information, this is the clinician’s determination of the patient’s condition.
- Plan: A roadmap detailing the proposed treatment, recommendations, or future investigations. This outlines the steps going forward.
Podiatry SOAP Note
- Subjective: This encompasses the patient’s verbal account of their symptoms, feelings, and concerns. It’s their perspective on what’s happening.
- Objective: Here, the podiatrist documents their observations and findings from the physical examination. It’s rooted in measurable or observable facts.
- Assessment: After analyzing the subjective and objective data, the podiatrist concludes a diagnosis or lists potential diagnoses (differential diagnoses).
- Plan: Similar to the General Note, this details the treatment, interventions, or further investigations that the podiatrist recommends.
Podiatry Note Templates
Templates act as a backbone to any clinical documentation, ensuring consistency and completeness. Below are the structured outlines for both the General Podiatry Note and the Podiatry SOAP Note that can be employed during patient encounters.
General Podiatry Note Copy Snippet Copied!
Date of Visit: [Date]
Presenting Complaint: [Main problem or concern]
History of Present Illness: [Detailed account of symptoms]
Past Medical History: [Relevant medical history]
Physical Examination: [Exam findings]
Plan: [Recommended treatment or next steps]
Podiatry SOAP Note Copy Snippet Copied!
Date of Visit: [Date]
Subjective: [Patient’s description of symptoms]
Objective: [Physical exam findings]
Assessment: [Diagnosis or differential diagnoses]
Plan: [Treatment or next steps]
Podiatry Note Example
Here are two hypothetical patient scenarios to demonstrate how the templates above templates can be filled out in actual practice situations.
General Podiatry Note Example
- Full Name: Emily Smith
- Age: 42
- Gender: Female
- Contact Info: 789 Maple Lane, Evergreen, Phone: (555) 789-0123, Email: firstname.lastname@example.org
- Other Identifiers: Patient ID: ES8741, Date of Birth: 05/22/1981
Date of Visit: October 27, 2023
Presenting Complaint: Pain in the right heel for 3 weeks.
History of Present Illness: Sharp pain, especially in the mornings. No injury was recalled. No swelling or redness.
Past Medical History: Asthma. No known drug allergies.
Physical Examination: Mild tenderness in the right heel’s plantar region. No swelling.
Diagnosis: Plantar fasciitis.
Plan: Stretching exercises, NSAIDs, and a follow-up in 2 weeks.
Podiatry SOAP Note Example
- Full Name: John Doe
- Age: 35
- Gender: Male
- Contact Info: 123 Elm Street, Springfield, Phone: (555) 123-4567, Email: email@example.com
- Other Identifiers: Patient ID: JD2356, Date of Birth: 01/15/1988
Date of Visit: July 14, 2023
Subjective: “I’ve noticed some discomfort and itching between my toes for the past few weeks.”
Objective: Erythema and scaling between the third and fourth toes of the left foot, with a slight odor.
Assessment: Athlete’s foot (Tinea Pedis).
Plan: Recommend over-the-counter antifungal cream, keep feet dry, and follow up if no improvement in 2 weeks.
Documenting patient encounters in podiatry is crucial for providing consistent care, tracking progress, and sharing information with other healthcare providers.
The key is to be thorough, clear, and concise when using the General Podiatry Note or the SOAP format. Both templates offer structure and ensure that all necessary information is included, enabling practitioners to deliver the best care to their patients.
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