SOAP NOTE TEMPLATE Review the Rubric for more Guidance Demographics

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

#1 An action item that resonated with my role as a clinical nurse coordinator is the ability to enhance quantitative reasoning. It is important to show

#1 An action item that resonated with my role as a clinical nurse coordinator is the ability to enhance quantitative reasoning. It is important to show that “the most successful population health initiatives have demonstrated their effectiveness through distinctive quality improvement methods that combine thinking about assessment, outcomes, and costs

ASSESSMENT. Use template To Prepare: · Identify an individual—an actual

ASSESSMENT. Use template To Prepare: · Identify an individual—an actual or symbolic friend—to whom you will write to advocate for civic engagement to advance health equity. · Access the Letter to a Friend: Advocacy for Health Equity template document. Review the required elements of the letter and consider how to