Week 6 SOAP NOTE
Create a SOAP NOTE using the guidelines and template provided below.
CC: My period is 22 days, I have pelvic pain and also noted some dark vaginal bleeding since yesterday.
Guidelines:
Subjective Information: “CC”, HPI :OPQRST IF f/u: health status since the last visit, response to therapies. PMH, PSH, FH, ROS complete.
Objective Information: Complete physical exam with critical elements related to subjective data.
Assessment: Minimum of 3 differentials supported by S + O data Final diagnosis noted, and optimal and thorough subjective and objective assessment is presented for final diagnosis.
Plan: Diagnostic tests/therapies/follow-up, Patient education, health promotion. Medications listed with dosage/SE/Education/
Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence-based reasoning & literature in designing plan of care, compare to plan of care implemented.
SOAP NOTE
Name: | Date: | Time: |
Age: 27 years | Sex: Female | |
SUBJECTIVE | ||
CC: My periods is 22 days, I have pelvic pain and also noted some dark vaginal bleeding since yesterday.
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HPI: (Use OLD CARTS tool)
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Medications:
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PMH: Allergies: Medication Intolerances: Immunizations: Chronic Illnesses/Major traumas: Hospitalizations/Surgeries (include delivery of pregnancies here)
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Family History
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Social History
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ROS | ||
General
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Cardiovascular
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Skin
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Respiratory
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Eyes
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Gastrointestinal
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Ears
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Genitourinary/Gynecological
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Nose/Mouth/Throat
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Musculoskeletal
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Breast
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Neurological
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Heme/Lymph/Endo
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Psychiatric
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OBJECTIVE | ||
Weight: BMI: | Temp: | BP: |
Height: | Pulse: | Resp: |
General Appearance
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Skin
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HEENT
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Cardiovascular
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Respiratory
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Gastrointestinal
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Breast
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Genitourinary
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Musculoskeletal
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Neurological
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Psychiatric
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Lab Tests (list the results if you have them)
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Special Tests (done or ordered during the OV) No special tests ordered.
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Diagnosis – include the appropriate ICD – 10 Code for each diagnosis used | ||
Primary Diagnosis Differential Diagnoses (these must be different from the Primary Diagnosis)
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Plan/Therapeutics (explain fully) | ||
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Evaluation of patient encounter |
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