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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