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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References
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