ANSWER
Based on the given principles, the following is a structured outline for your SOAP note:
SOAP Note Format
Name of the patient: [Insert Name]
Date: [Insert Date]
[Insert Time]
Allergies: [Enter any allergies you may have]
Current Drugs: [List all drugs now taken]
S: Intimate Information
Chief Complaint (CC): [Enter the main issue of the patient, such as “Sore throat for 3 days.”]
History of Present Illness (HPI): [Explain the principal complaint’s start, location, duration, features, aggravating and relieving causes, and severity (OLDCARTS).]
Past Medical History (PMH): [Add pertinent familial, medical, or surgical history here.]
Social History (SH): [Living situation, drug and alcohol use, smoking, etc.]
Review of Systems (ROS): [Add relevant CC-related advantages and disadvantages.]
O: Objective Information
Vital Signs: [Note the temperature, oxygen saturation, pulse, blood pressure, and respiration rate.]
Physical Exam: [Explain specific results derived from the systems analyzed, such as:]
General: [Looking, degree of anguish, etc.]
HEENT: [Details of the head, eyes, ears, nose, and throat]
Lungs: [Respiratory effort, breath sounds]
Heart: [Rhythm, murmurs, heart rate]
Abdomen: [Masses, tenderness]
Extremities: [strength, edema]
Behavior: [Explain how the patient behaves, communicates, or complies with the test.]
A: Evaluation
[Primary diagnosis in light of findings]
Differential Diagnoses: [Enumerate two to three possible diagnoses, backed by findings, in order of likelihood.]
P: Make a plan
[Medications prescribed, dosage, frequency, and duration] is the treatment plan.
Diagnostics: [Lab work, imaging, or other research requested.]
Education: [Teachers’ instructions on their disease or how to take their medications.]
[Timing and goal of follow-up, such as “Return in 7 days for re-evaluation.”]
References: [If relevant, indicate the specialists to whom the patient has been referred along with the rationale.]
Make sure the SOAP note is clear, succinct, and formatted correctly, paying close attention to grammar. If you need assistance creating a SOAP note for a particular patient scenario, please let me know!
QUESTION
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
S =Subjective data: Patient’s Chief Complaint (CC).O =Objective data: Including client behavior, physical assessment, vital signs, and meds.A =Assessment: Diagnosis of the patient’s condition. Include differential diagnosis.P =Plan: Treatment, diagnostic testing, and follow up
- Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.
- You must use the template provided. Turnitin will recognize the template and not score against it.
- Your submission will be reviewed for plagiarism through Turnitin.