Problem-Oriented / SOAP-Consistent

Problem list with Assessment → ED Interventions → Discharge Plan → Disposition.

ASSESSMENT & PLAN

{Overall instructions}
{Use a problem-oriented, SOAP-consistent layout. Number each problem sequentially.}
{Assessment: 1–3 sentences unless key positives/negatives require bullets. Do not include treatments here.}
{Plan is split into ED Interventions (what occurred in the ED) and Discharge Plan (instructions, return precautions, discharge medications).}
{Delete optional lines if no data is present.}
{Insert a blank line before each section header (Assessment, ED Interventions, Discharge Plan, Disposition).}

{Repeat for each problem}
{Always print the problem number and problem name.}
[Problem Number]. [Problem Name]

Assessment:
[Summarize key positives/negatives that contribute to clinical reasoning. Limit to what impacts decision making. Do not include treatments.]

ED Interventions:
- [Interventions/procedures performed in ED. Delete line if none.]
- [Medications administered in ED only. Delete if none.]
- [Diagnostics ordered or reviewed in ED, with brief rationale. Delete if none.]
- [Consults performed in ED, if any. Delete if none.]

Discharge Plan:
- [Prescriptions provided at discharge, with brief rationale. Delete if none.]
- [Condition-specific patient education. Delete if none.]
- [Follow-up instructions. Delete if none.]
- [Return precautions: “Return to the ED for worsening symptoms or new concerns.” unless otherwise specified.]

Disposition:
[Disposition status]

{Optional shared decision-making block — include only if present}
["Risks and benefits have been discussed with the patient."] [Insert brief rationale.]

{Optional SDOH block — include only if present}
[SDOH factors: Insert relevant items.]

1. Foot Infection

Assessment: Patient presents with right foot swelling, erythema, tenderness, and subjective fever. Physical exam shows mildly swollen right foot with erythema to the ankle, tender to palpation, CMS intact throughout, good pulses (both dorsal pedal and posterior tibial).

ED Interventions:
- Applied Ace wrap to right foot.
- Administered initial oral dose of Bactrim due to cephalosporin allergy.
- Given ibuprofen for pain control and swelling.

Discharge Plan:
- Prescribed oral Bactrim for ongoing therapy.
- Patient education on antibiotic use, pain management, and use of Ace wrap for swelling.
- Follow-up instructions: Monitor symptoms and follow up with primary care if concerns persist.
- Return precautions: Return to the ED for worsening symptoms or new concerns.

Disposition: Discharged into police custody.