Template and rubric are included. SOAP NOTE TEMPLATE Review the Rubric for more Guidance Demographics

 Template and rubric are included.

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

This assignment is for an initial psych interview Diagnosis: Major depressive disorder location: miami, Florida Comprehensive

This assignment is for an initial psych interview Diagnosis: Major depressive disorder location: miami, Florida Comprehensive Psychiatric Evaluation Template With Psychotherapy Note Encounter date: ________________________ Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____ Reason for Seeking Health Care: ______________________________________________ HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ SI/HI: _______________________________________________________________________________ Sleep:  _________________________________________    

Professional Role Development “Nursing research involves much planning and attention to details, yet novice and seasoned nurse researchers often

Professional Role Development “Nursing research involves much planning and attention to details, yet novice and seasoned nurse researchers often overlook the day-to-day operations required to conduct research studies. Project management is a set of iterative steps that can facilitate the process of conducting nursing research” (Rew et al., 2020). As

Module 3 Discussion      Caring for Chinese, Filipino, & Vietnamese Populations

Module 3 Discussion      Caring for Chinese, Filipino, & Vietnamese Populations After studying  Module 3: Lecture Materials & Resources, discuss the following: A. Describe health and illness practices that may augment problems associated with the treatment of hypertension for Chinese-American clients.  B. Describe the locus-of-control variable that some Filipino