advice health: I need your expertise  | Nursing

Clinical Requirement:

I need your expertise  GraduateSOAPNOTETEMPLATE.docx SOAP Note Template Encounter date: ________________________ Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____ Reason for Seeking Health Care: ______________________________________________ HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________ Current perception of Health: Excellent Good Fair Poor Past Medical History · Major/Chronic Illnesses____________________________________________________ · Trauma/Injury ___________________________________________________________ · Hospitalizations __________________________________________________________ Past Surgical History___________________________________________________________ Medications: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Family History: ____________________________________________________________ Social history: Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________ Employment Status: ______ Current/Previous occupation type: _________________ Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________ Sexual orientation: _______ Sexual Activity: ____ Contraception Use: ____________ Family Composition: Family/Mother/Father/Alone : _____________________________ Health Maintenance Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____ Exposures: Immunization HX: Review of Systems: General: HEENT: Neck: Lungs: Cardiovascular: Breast: GI: Male/female genital: GU: Neuro: Musculoskeletal: Activity & Exercise: Psychosocial: Derm: Nutrition: Sleep/Rest: LMP: STI Hx: Physical Exam BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI ( percentile) _____ General: HEENT: Neck: Pulmonary: Cardiovascular: Breast: GI: Male/female genital: GU: Neuro: Musculoskeletal: Derm: Psychosocial: Misc. Significant Data/Contributing Dx/Labs/Misc. Plan: Differential Diagnoses 1. 2. 3. Principal Diagnoses 1. 2. Plan Diagnosis Diagnostic Testing: Pharmacological Treatment: Education: Referrals: Follow-up: Anticipatory Guidance: Diagnosis Diagnostic Testing: Pharmacological Treatment: Education: Referrals: Follow-up: Anticipatory Guidance: Signature (with appropriate credentials): __________________________________________ Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________ DEA#: 101010101 STU Clinic LIC# 10000000 Tel: (000) 555-1234 FAX: (000) 555-12222 Patient Name: (Initials)______________________________ Age ___________ Date: _______________ RX ______________________________________ SIG: Dispense: ___________ Refill: _________________ No Substitution Signature: ____________________________________________________________ Copyright © MVJ 2018 image1.png advchealthwk7assign2.docx 1. complete physical examination that will be performed on a person that is 18 years old or older. 2. Submit a typed SOAP Note of the 18years old physical assessment. Make sure to follow the proper sequential order in your physical assessment and use the correct terminology in your SOAP Note.  SOAP Note Template Encounter date: ________________________ Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____ Reason for Seeking Health Care: ______________________________________________ HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________ Current perception of Health: Excellent Good Fair Poor Past Medical History · Major/Chronic Illnesses____________________________________________________ · Trauma/Injury ___________________________________________________________ · Hospitalizations __________________________________________________________ Past Surgical History___________________________________________________________ Medications: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Family History: ____________________________________________________________ Social history: Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________ Employment Status: ______ Current/Previous occupation type: _________________ Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________ Sexual orientation: _______ Sexual Activity: ____ Contraception Use: ____________ Family Composition: Family/Mother/Father/Alone : _____________________________ Health Maintenance Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____ Exposures: Immunization HX: Review of Systems: General: HEENT: Neck: Lungs: Cardiovascular: Breast: GI: Male/female genital: GU: Neuro: Musculoskeletal: Activity & Exercise: Psychosocial: Derm: Nutrition: Sleep/Rest: LMP: STI Hx: Physical Exam BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI ( percentile) _____ General: HEENT: Neck: Pulmonary: Cardiovascular: Breast: GI: Male/female genital: GU: Neuro: Musculoskeletal: Derm: Psychosocial: Misc. Significant Data/Contributing Dx/Labs/Misc. Plan: Differential Diagnoses 1. 2. 3. Principal Diagnoses 1. 2. Plan Diagnosis Diagnostic Testing: Pharmacological Treatment: Education: Referrals: Follow-up: Anticipatory Guidance: Diagnosis Diagnostic Testing: Pharmacological Treatment: Education: Referrals: Follow-up: Anticipatory Guidance: Signature (with appropriate credentials): __________________________________________ Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________ DEA#: 101010101 STU Clinic LIC# 10000000 Tel: (000) 555-1234 FAX: (000) 555-12222 Patient Name: (Initials)______________________________ Age ___________ Date: _______________ RX ______________________________________ SIG: Dispense: ___________ Refill: _________________ No Substitution Signature: ____________________________________________________________