Soap Note x 3 (24 Hours)
1) Submit 1 document per part
Part 1: Complete the file “Template Soap Note” taking into account the following information:
Diagnosis: (D64.9) Anemia, unspecied
Female
39 Years
Part 2: Complete the file “Template Soap Note” taking into account the following information:
Diagnosis: (G44.51) Hemicrania continua
Female
62 Years
Part 3: Complete the “Template Soap Note” taking into account the following information:
Diagnosis: (E73.9) Lactose intolerance, unspecied
Male
58 years
2)¨******APA norms, please use headers
All paragraphs must be narrative and cited in the text- each paragraphs
Bulleted responses are not accepted
Dont write in the first person
Dont copy and pase the questions.
Answer the question objectively, do not make introductions to your answers, answer it when you start the paragraph
Submit 1 document per part
3) It will be verified by Turnitin and SafeAssign
4) Minimum 4 references per part not older than 5 years
Patient Initials: |
Pt. Encounter Number: |
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Date: |
Age: |
Sex: |
Allergies: Advanced Directives: |
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SUBJECTIVE |
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CC: |
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HPI: Onset: Location: Duration: Characteristics: Aggravating Factors: Relieving Factors: Treatment: |
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Current Medications: |
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PMH Medication Intolerances: Chronic Illnesses/Major traumas: Screening Hx/Immunizations Hx: Hospitalizations/Surgeries: |
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Family History: |
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Social History: |
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ROS |
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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 |
Genitourinary/Gynecological |
SOAP NOTE
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 |
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Weight BMI |
Temp |
BP |
Height |
Pulse |
Resp |
PHYSICAL EXAMINATION |
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General Appearance |
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HEENT |
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Genitourinary |
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Lab Tests |
Special Tests |
Diagnosis |
· Primary Diagnosis- Evidence for primary diagnosis should be documented in your Subjective and Objective exams. o Differential Diagnoses- Include three minimum diagnoses PLAN including education |
References |