create 45 soap notes addressing different disorders H e a l t h M e d i c a l
Create 45 Soap notes addressing different disorders for the body. The soap notes must address the adult population only.Please address the ROS(review of systems) and PE(physical examination).In your soap template include medications, ICD 10 diagnosis codes ,CPT billing codes and referrals if needed. Attached you will have sample of the templates used. No need to have in text citations or references.Please follow format. Below are the textbooks used.
•Subjective: What details did the patient provide regarding his or her personal and medical history?
•Objective: What observations did make during the physical assessment?
•Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
•Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies?
Chief Complain (CC):
History of Present Illness (HPI):
Last Menstrual Period (LMP- if applicable)
Past Medical History:
Social History (alcohol, drug, or tobacco use):
Review of Systems
(Remember to inquire about body systems relevant to the chief complaint and HPI)
Please remember to include an assessment of all relevant systems based on the CC and HPI. The following systems are required in all SOAP notes. If it is a child, include the Tanner stage. You will proceed to assess pertinent systems.
Vital Signs/ Height/Weight:
A: Differential Diagnosis
Please rule out all differential diagnosis with subjective and objective data and/or lab-work.
B: Medical Diagnosis
Rule in diagnosis with subjective and objective data and lab-work. They need to let us know how they arrived at the diagnosis.
- Prescriptions with dosage, route, duration, amount prescribed, and if refills are provided
- Diagnostic testing
- Problem oriented education
- Health Promotion/Maintenance Needs
Cultural Diversity: What cultural considerations would you suggest for this patient?
Patient/Family Education: If patient is currently on any medications, please address if you want them to discontinue or continue. You always want this to be clear at the end of the visit.
B: Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit —F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic)
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