*****complete soap note****
patient is a 33 y/o female with std with no phx
Subjective: What details did the patient provide regarding her personal and medical history?
Objective: What observations did you make during the physical assessment?
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan and patient education.
Reflection notes: What would you do differently in a similar patient evaluation?
Examine yourself are you reaching your current goals, learning new skills, and receiving a variety of patient experiences?