[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-277282-105":53,"doc-detail-277282-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","soap-note-post-traumatic-headache-assessment-and-plan","SOAP NOTE - Post-traumatic headache assessment and plan","","SOAP note template documenting a patient’s headache presentation using a structured approach. The subjective section records headache onset timing, while the differential diagnosis rationale supports post-traumatic headache and explains why post-concussional syndrome is most likely. The objective portion logs vital signs and physical exam findings, and the assessment outlines imaging with a scheduled brain MRI to rule out life-threatening causes. The plan includes symptom management with Midrin and Motrin, follow-up to review MRI results, and health maintenance counseling.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":11,"@type":70,"position":76},"https://docshare.wps.com/template/presentations/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/soap-note-post-traumatic-headache-assessment-and-plan/277282/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/soap-note-post-traumatic-headache-assessment-and-plan/277282.png","ImageObject",442,249,{"name":88,"@type":89},"Seraphina","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-10-19","2026-09-15",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What diagnosis is considered most likely for the patient’s headache?","Question",{"text":109,"@type":110},"The note concludes that a post-traumatic headache is the most likely diagnosis, with post-concussional syndrome as the later coding once other causes are ruled out.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Why is a brain MRI scheduled?",{"text":114,"@type":110},"An MRI is scheduled to rule out serious causes such as a subdural hematoma or brain tumor that could be life-threatening.",{"name":116,"@type":107,"acceptedAnswer":117},"What medications and instructions are included in the treatment plan?",{"text":118,"@type":110},"The patient is prescribed Motrin 800 mg TID and advised to use Midrin for breakthrough severe pain. She is also counseled about the possible duration of headaches and reassured after imaging is planned.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},277282,1791721163,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":8,"category_name":11,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":47,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":73},962075114101,"https://ap-avatar.wpscdn.com/avatar/e000253a75eb197efd?x-image-process=image/resize,m_fixed,w_180,h_180&k=1780044092746381165","SOAP NOTE\nPATIENT PROFILE/IDENTIFYING DATA\n__________________________________________________________________________________________________________________________________________________________________________________________\nProblem List:\nHeadache onset 8/28/01\n______________________________________________________    _      _\nSUBJECTIVE\n_______________________________________________________________________________________________________________________________________________________________________________________\nDIFFERENTIAL DIAGNOSES/RATIONALE:\n_______________________________________________________________________________________________________________________  ___\n__________________________________________________________________________________________________________________        ______\n_______________________________________________________________________________________________________________________\n__________________________________________________________________________________________________________________________\n__________________________________________________________________________________________________________________________\nHPI:\nPast Medical History:\nSocial History:\n________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________\nROS:\n________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________\nPertinent positives/negatives:\n________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________\n________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________\n________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________\nOBJECTIVE:\nVital Signs: Weight 179 lbs, Height 65 inches, Temperature 99.2 orally, Pulse\n76, Resp 20, BP 114/72.\nPhysical Exam:\nDDX:\nPost-traumatic headache- positives/negatives same as above. This is the most likely diagnosis at this point.\nASSESSMENT/PLAN\n1. Post-traumatic headache-most likely diagnosis based on all above information (ICD code for general headache is 784.0, and she will be coded as such until further evaluation). Post concussional syndrome (ICD code 310.02) is common and has varied severity. The patient may not have lost consciousness (as in this patient) but suffered trauma (can be minimal as in this patient). The triad of symptoms includes headaches, dizziness, and poor concentration (Patten, 1996). To further evaluate her, an MRI of the brain was scheduled for the next day, in order to rule out other causes of headache. This is essential in this case, because a subdural hematoma or brain tumor could be life threatening. Once these are ruled out, her code will be post concussional syndrome (310.02). Headaches, post trauma, (tension type or migraine type) can be treated with the usual symptomatic/prophylactic medications. Most patients improve after 3 months, and reassurance serves maximum benefit (Goetz, 1999). She was counseled on the length of time of these headaches, sometimes weeks to months, and encouraged to try Midrin which she already has the prescription for, to try to alleviate the headaches when th","cbCaicx2YXxImYU3","https://ap.wps.com/l/cbCaicx2YXxImYU3","docx",20477,"English","# SUBJECTIVE\n## HPI\n## ROS\n## Pertinent positives/negatives\n# OBJECTIVE\n## Vital Signs\n## Physical Exam\n# ASSESSMENT/PLAN\n## Differential diagnosis and rationale\n## Treatment plan\n## Follow-up and health maintenance","[{\"question\":\"What diagnosis is considered most likely for the patient’s headache?\",\"answer\":\"The note concludes that a post-traumatic headache is the most likely diagnosis, with post-concussional syndrome as the later coding once other causes are ruled out.\"},{\"question\":\"Why is a brain MRI scheduled?\",\"answer\":\"An MRI is scheduled to rule out serious causes such as a subdural hematoma or brain tumor that could be life-threatening.\"},{\"question\":\"What medications and instructions are included in the treatment plan?\",\"answer\":\"The patient is prescribed Motrin 800 mg TID and advised to use Midrin for breakthrough severe pain. She is also counseled about the possible duration of headaches and reassured after imaging is planned.\"}]","SOAP NOTE - Post-traumatic headache assessment and plan | DOCX",1789499357]