s #3: | Nursing

Clinical Requirement:

SOAP3.docx SOAP NOTE TEMPLATE Review the Rubric for more Guidance Demographics Chief Complaint (Reason for seeking health care) History of Present Illness (HPI) Allergies Review of Systems (ROS) General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: Nutrition: Sleep/Rest: LMP: STI Hx: Vital Signs Labs Medications Past Medical History Past Surgical History Family History Social History Health Maintenance/ Screenings Physical Examination General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: Diagnosis Differential Diagnosis ICD 10 Coding Pharmacologic treatment plan Diagnostic/Lab Testing Education Anticipatory Guidance Follow up plan Prescription See Below (scroll down) References Grammar EA#: 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:____________________________________________________________ Signature (with appropriate credentials):_____________________________________ References (must use current evidence-based guidelines used to guide the care [Mandatory])