SOAP NOTE
Title: EC
Date:
Time:
Age: 47 years
Intercourse: Feminine
SUBJECTIVE
CC: I’ve been having ache in my pelvis space for the previous month, my final menstrual durations was 7 month in the past however I’ve been recognizing.
HPI: (Use OLD CARTS instrument)
Medicines:
PMH:
Allergic reactions:
Medicine Intolerances:
Immunizations:
Continual Diseases/Main traumas:
Hospitalizations/Surgical procedures (embody supply of pregnancies right here)
Household Historical past
Social Historical past
ROS
Normal
Cardiovascular
Pores and skin
Respiratory
Eyes
Gastrointestinal
Ears
Genitourinary/Gynecological
Nostril/Mouth/Throat
Musculoskeletal
Breast
Neurological
Heme/Lymph/Endo
Psychiatric
OBJECTIVE
Weight: BMI:
Temp:
BP:
Peak:
Pulse:
Resp:
Normal Look
Pores and skin
HEENT
Cardiovascular
Respiratory
Gastrointestinal
Breast
Genitourinary
Musculoskeletal
Neurological
Psychiatric
Lab Exams (record the outcomes when you’ve got them)
Particular Exams (achieved or ordered in the course of the OV)
No particular checks ordered.
Analysis – embody the suitable ICD – 10 Code for every analysis used
Major Analysis
Differential Diagnoses (these have to be totally different from the Major Analysis)
Plan/Therapeutics (clarify absolutely)
Analysis of affected person encounter
References
1
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