Documentation SOAP Note Create a focused exam SOAP note based on a case during your clinicals. Can be any visit expected at a family practice visit for a 46 y/o male patient. References should be guidelines that support the treatment plan and related condition/s.
Subjective
Opener presentation of the patient (age/sex/presentation of issue with key past DX) 46 y/o male patient
History of present illness (HPI) (OldCarts)
Other related past medical history
Review of systems (ROS)
Objective
Vital signs and physical exam on pertinent body systems
Assessment
Assessment including differentials and specific labs or X-rays reviewed
Plan
Explain the plan that you are suggesting or that was done, including any education, further work-up, specific medications with doses and frequency, consultations/referral, and follow-up
At least 3 references. Not older than 5 years old. APA format
Documentation SOAP Note Create a focused exam SOAP note based on a case during
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