Reference no: EM133937316
Assignment Instructions
Consider constructing a Word document ‘SOAP note template' and use it to assemble your note. By doing this you can use the template for efficiently constructing your SOAP notes such that you will be able to copy-and-paste for your weekly assignments. NOTE: If your faculty person requests to see your SOAP note template you will be required to send it to them for review. Get top-notch online assignment help now.
Sections of the SOAP note should be addressed if they are pertinent to the presenting chief complaint.
Typhon Encounter #:
Type of Note: Focused or Comprehensive
Subjective (S):
CC: chief complaint - What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.
HPI: Who is the historian? Is the historian reliable? History of Present Illness - use the "OLDCART" approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
Past medical history (PMH) - This should include illness/diagnosis, conditions, traumas, hospitalizations, and surgical history that is pertinent to the visit. Include dates if possible.
Reproductive history: GTPAL, STIs, prenatal care, LMP, contraceptive methods, sexual and menstrual history. Include dates if possible.
Allergies: State the offending medication/food and the reactions. Medications: Names, dosages, routes, frequency, and indications.
Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work, and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.
Family history: Use terms like maternal, paternal and the diseases and the ages they were deceased or diagnosed if known.
Health Maintenance/Promotion - Required for all SOAP notes: Immunizations, exercise, diet, screening, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age-appropriate indicators, Healthy People 2030, and Centers for Disease Control and Prevention (CDC). This should reflect patient's current recommendations. Up to date on health maintenance/promotion will NOT be accepted. Requires references.
Review of systems (ROS) -
[Refer to your course modules and the Bickley E-text (Bates Guide) as a guide when conducting your ROS to make sure you have not missed any important symptoms,
particularly in areas that you have not already thoroughly explored while discussing the history of present illness.]
You would also want to include any pertinent negatives or positives that would help with your differential diagnosis. For acute episodic or follow-up visits (focused note) you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc. As opposed to a comprehensive visit which would address each system.