“CC”, HPI :OPQRST

Create a SOAP NOTE using the guidelines and template provided bellow.

Topic: I have a discomfort on my abdomen and I’m always tired.

CC: 30 y/o female with multiple sexual partners without protection, flu-like symptoms, fatigue and mouth ulcers.

 

Guidelines:

Subjective Information: “CC”, HPI :OPQRST IF f/u: health status since last visit, response to therapies. PMH, PSH, FH, ROS complete.

Objective Information: Complete physical exam with critical elements related to subjective data.

Assessment: Minimum of 3 differentials supported by S + O data Final diagnosis noted, and optimal and thorough subjective and objective assessment is presented for final diagnosis.

Plan: Diagnostic tests/therapies/follow-up, Patient education, health promotion. Medications listed with dosage/SE/Education/

Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence-based reasoning & literature in designing plan of care, compare to plan of care implemented.

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    SOAPNOTETEMPLATE.doc