SOAP NOTE TEMPLATE Review the Rubric for more GuidanceDemographics

SOAP NOTE TEMPLATE

Review the Rubric for more Guidance

Demographics

Chief Complaint (Reason for seeking health care)

History of Present Illness (HPI)

Allergies

Review of Systems (ROS)

General:

HEENT:

Neck:

Lungs:

Cardio

Breast:

GI:

M/F genital:

GU:

Neuro

Musculo:

Activity:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

Vital Signs

Labs

Medications

Past Medical History

Past Surgical History

Family History

Social History

Health Maintenance/ Screenings

Physical Examination

General:

HEENT:

Neck:

Lungs:

Cardio

Breast:

GI:

M/F genital:

GU:

Neuro

Musculo:

Activity:

Psychosocial:

Derm:

Diagnosis

Differential Diagnosis

ICD 10 Coding

Pharmacologic treatment plan

Diagnostic/Lab Testing

Education

Anticipatory Guidance

Follow up plan

Prescription

See Below (scroll down)

References

Grammar

EA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age ___________

Date: _______________

RX ______________________________________

SIG:

Dispense: ___________ Refill: _________________

No Substitution

Signature:____________________________________________________________

Signature (with appropriate credentials):_____________________________________

References (must use current evidence-based guidelines used to guide the care [Mandatory])

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

The purpose of this assignment is to complete a review of a screening tool utilized by nurse practitioners in maintaining individual, family, or

The purpose of this assignment is to complete a review of a screening tool utilized by nurse practitioners in maintaining individual, family, or community health. PHQ-9 (Patient Health Questionnaire-9) Your presentation should: 1. Identify and select a screening tool   2. Research of ethical, economical and legal issues relative to the practice in relation to

see attachedSMART GoalGoal 1Specific: Learning decision-making skills from my

see attached SMART Goal Goal 1 Specific: Learning decision-making skills from my preceptor to broaden my expertise and present as a great leader. Measurable: Improvement in decision-making skills Attainable: Attend meetings, collect data, ask questions Results-focused: Enhance ability to make accurate and effective decision for the resident and the company.