Create a focused exam soap note based on a case

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Reference no: EM133886620

Discussion Post: Documentation SOAP Note

Create a focused exam SOAP note based on a case during your clinicals. This same case will be used for your presentation video. References should be guidelines that support the treatment plan and related condition/s. Get the instant assignment help.

I. Subjective

1) Opener presentation of the patient (age/sex/presentation of issue with key past DX)
2) History of present illness (HPI) (OldCarts)
3) Other related past medical history
4) Review of systems (ROS)

II. Objective

1) Vital signs and physical exam on pertinent body systems

III. Assessment

1) Assessment including differentials and specific labs or X-rays reviewed

IV. Plan

1) Explain the plan that you are suggesting or that was done, including any education, further work-up, specific medications with doses and frequency, consultations/referral, and follow-up.

Reference no: EM133886620

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