Description
The SOAP note is a provider’s report note. please fill it up as bullets.I have provided a few photos of the patient’s health assessment, Tina Jons. All the information and the corresponding main category are provided in the second column of the attached photos. Please take a look at the example provided as a reference.the photo names start with “example” are just an example please do not copy from it just have an idea how to formal it. The photos names start with “Tina” is the actual information should come from. Please fill up the provided world document.
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Name:
Section:
Week 4
Shadow Health Digital Clinical Experience Health History Documentation
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Immunization History:
Health Maintenance:
Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings,
and children):
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint,
History of Present Illness, and History). Remember that the information you include in this
section is based on what the patient tells you. To ensure that you include all essentials in your
case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not
restate HPI data here.
HEENT:
Neck:
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Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin:
Hematologic:
Endocrine:
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