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.

 

HPI:  (Use OLD CARTS tool)

 

Medications:

 

PMH:

Allergies: 

Medication Intolerances:

Immunizations:

Chronic Illnesses/Major traumas:

Hospitalizations/Surgeries (include delivery of pregnancies here)

 

Family History

 

Social History

 

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

 

Skin

 

HEENT

 

Cardiovascular

 

Respiratory

 

Gastrointestinal

 

Breast

 

Genitourinary

 

Musculoskeletal

 

Neurological

 

Psychiatric

 

Lab Tests (list the results if you have them)

 

Special Tests (done or ordered during the OV)

No special tests ordered.

 

 Diagnosis – include the appropriate ICD – 10 Code for each diagnosis used
Primary Diagnosis

Differential Diagnoses (these must be different from the Primary Diagnosis)

 

Plan/Therapeutics (explain fully)
 

 Evaluation of patient encounter

 

References

1

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