Week 10 SOAP NOTE
SOAP NOTE
Name: EC | Date: | Time: |
Age: 47 years | Sex: Female | |
SUBJECTIVE | ||
CC: I have been having pain in my pelvis area for the past month, my last menstrual periods was 7 month ago but I have been spotting.
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HPI: (Use OLD CARTS tool)
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Medications:
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PMH:
Allergies: Medication Intolerances: Immunizations: Chronic Illnesses/Major traumas: Hospitalizations/Surgeries (include delivery of pregnancies here)
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Family History
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Social History
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ROS | ||
General
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Cardiovascular
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Skin
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Respiratory
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Eyes
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Gastrointestinal
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Ears
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Genitourinary/Gynecological
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Nose/Mouth/Throat
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Musculoskeletal
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Breast
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Neurological
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Heme/Lymph/Endo
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Psychiatric
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OBJECTIVE | ||
Weight: BMI: | Temp: | BP: |
Height: | Pulse: | Resp: |
General Appearance
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Skin
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HEENT
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Cardiovascular
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Respiratory
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Gastrointestinal
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Breast
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Genitourinary
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Musculoskeletal
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Neurological
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Psychiatric
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Lab Tests (list the results if you have them)
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Special Tests (done or ordered during the OV)
No special tests ordered.
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Diagnosis – include the appropriate ICD – 10 Code for each diagnosis used | ||
Primary Diagnosis
Differential Diagnoses (these must be different from the Primary Diagnosis)
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Plan/Therapeutics (explain fully) | ||
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Evaluation of patient encounter
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References
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