SOAP NOTE: Name, Date, Time, Age, Sex, Subjective CC

Question

SOAP NOTE Name: Date: Time: Age: Sex: SUBJECTIVE CC: Re SOAP NOTE Name: Date: Time: Age: Sex: SUBJECTIVE CC: Reason given by the patient for seeking medical care “in quotes” HPI: Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness. Medications: (list with reason for med ) PMH Allergies: Medication Intolerances: Chronic Illnesses/Major traumas Hospitalizations/Surgeries Family History Social History Safety status ROS General Cardiovascular Skin Respiratory Eyes Gastrointestinal Ears Genitourinary/Gynecological Nose/Mouth/Throat Musculoskeletal Breast Neurological Heme/Lymph/Endo Psychiatric OBJECTIVE Weight BMI Temp BP Height Pulse Resp General Appearance Healthy appearing adult female in no acute distress. Lab Tests Special Tests Diagnosis Differential Diagnoses · 1- · 2- · 3- Diagnosis Plan/Therapeutics · Plan: · Further testing · Medication · Education · Non-medication treatments Evaluation of patient encounter.

Dr. Jack HW Helper · Accepted Answer

The SOAP note is a crucial documentation tool in clinical practice that provides a structured approach to gathering and presenting patient information. This approach encompasses various patient-centric elements, including subjective complaints (CC), history of present illness (HPI), objective findings, and assessment or plan for treatment (Davis, 2020). In this analysis, we will explore the comprehensive structure of a SOAP note by filling out a hypothetical case study for a patient, D.K., a 22-year-old female presenting with specific symptoms, while following the given structure. Subjective Section Name: D.K. Date: 10/19/2018 Time: 10:00 AM Age: 22 y/o Sex: Female SUBJECTIVE CC: "I had mild fever, nausea, vomiting, vaginal spotting, and pain to my right side since last night." HPI: D.K., a 22-year-old female, presents with complaints of right lower abdominal pain quantified as 6-8 on a 10-point scale. She describes the pain as having begun the previous night and associates it with symptoms of nausea, vomiting (three episodes), and mild fever. Her gynecological history includes menarche at age 11, with regular 28-day cycles. D.K. is sexually active with one partner and employs condoms for contraception. Past medical history reveals no significant allergies, intolerances, or trauma, and she has not been hospitalized or undergone surgeries. Medications and History Medications: None. Family history: Mother is alive with controlled diabetes. Father is alive and in good health. D.K. has two healthy siblings, with no reported hereditary illnesses Social History: D.K. resides in a single-person household and identifies as Catholic. She denies alcohol and drug use, is a non-smoker, exercises regularly (walking 30-45 minutes three times a week), and has no pets or recent travel history. Review of Systems (ROS) General: Denies weight changes, fatigue, and any distress. Cardiovascular: Denies chest pain or palpitation; no edema or orthopnea. Respiratory: Denies cough or shortn

SOAP NOTE: Name, Date, Time, Age, Sex, Subjective CC ✓ Solved

SOAP NOTE Name: Date: Time: Age: Sex: SUBJECTIVE CC: Re

Paper For Above Instructions

Subjective Section

Medications and History

Review of Systems (ROS)

Objective Section

Physical Examination Findings

Assessment

Plan/Therapeutics & Education

Follow-up

Evaluation of Patient Encounter

References