Soap 3

SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive SOAP note is to be written usi

With your instructor’s permission, you may write an episodic SOAP note in place of the comprehensive. 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

Submission Instructions:

Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.
Attention: Complete and submit the assignment using the appropriate template in MS Word by 11:59 PM ET Friday.

Episodic Women’s Health SOAP Note Template

Encounter date:

Patient Initials: Gender: Age: Race/Ethnicity:

Subjective

Reason for Seeking Health Care:

History of Present Illness (HPI):

Allergies (Drug/Food/Latex/Environmental/Herbal):

Current Medications (including over the counter medications):

Past Medical History (PMH):

OB/GYN History:

Past Surgical History:

Family Medical History:

Social History:

Review of Systems (ROS)

Focus on systems affecting women’s health and inquire about systems relevant to the reason for the visit)

Physical Examination

Vital Signs

General Appearance

Include physical exam of all relevant systems based on the reason for the visit and the HPI. Perform a cardiopulmonary exam on all patients regardless of the reason for seeking care.

Significant Data/Contributing Dx/Labs/Misc

Assessment

Differential Diagnoses (3 minimum)

Primary Diagnoses

Plan

For each primary diagnosis, include laboratory/diagnostic tests, therapeutic/pharmacological therapy, referrals, and follow-up ordered and patient education done for this visit.

Include age-appropriate health promotion/maintenance/screening needs.

Remember that for every S (reason for the visit), there must be an O, A, and P (relevant exam, diagnosis, and plan). Always sign your notes.

DEA#: 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])

Comprehensive Women’s Health History and Physical Template

Encounter date:

Patient Initials: Gender: Age: Race/Ethnicity:

Reason for Seeking Health Care

History of Present Illness (HPI)

Allergies (Drug/Food/Latex/Environmental/Herbal)

Current Perception of Health

Current Medications (including over the counter)

Menstrual History

Age at Menarche

Last menstrual period

Menstrual Pattern

Cycle Length

Duration of Flow

Amount of Flow

Bleeding Pattern

Break through Bleeding

Gynecologic History

History of breast disease, breast feeding, use of self-breast exam, last mammogram (if applicable)

Previous GYN surgery (may include that in surgical history)

History of infertility

History of diethylstilbestrol (DES) use by patient’s mother

Last pap smear, history of abnormal pap

Pre-menopause/menopause

Vasomotor symptoms

Hormone Replacement Therapy

Sexual and Contraceptive History

Current method of contraception

Sexually active

Number of sexual partners

New partners in the 3-6 months

Condom use

History of sexual abuse

History of sexually transmitted infections (STIs)

Obstetric History (including complications)

Past Medical History (PMH)

Major/Chronic Illnesses

Trauma/Injury

Hospitalizations

Past Surgical History

Family Medical History

Social History

Living condition

Marital status

Education

Employment

Occupation

Social supports

Habits (smoking, alcohol use and illicit drugs use)

Health Maintenance

Age-appropriate health promotion/maintenance and screening history

Immunization history

Review of Systems (ROS)

General

Dermatology

HEENT

Neck

Pulmonary System

Cardiovascular System (CVS)

Breast

Gastrointestinal (GI) System

Genitourinary (GU) System

Female Genitalia

Musculoskeletal System

Neurological System.

Endocrine

Psychologic

Hematologic/Lymphatic

Physical Examination

Vital Signs

Blood Pressure (BP: Temperature Heart Rate (HR) Respiratory Rate (RR)

Height Weight Body Mass Index (BMI) Pain