Description
Write 8 SOAP Notes related to OB/GYN cases doctors appoinment (Ex: first, second and third trimester of pregnancy). NOT hospital setting. Race have to be Hispanic. Thank you.
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SOAP NOTE
Patient Initials:
Date:
Age:
Gender:
Advanced Directives:
SUBJECTIVE
CC: (Chief Complaint stated in the patient’s words)
HPI: Describe the course of the patient’s illness:
Onset:
Location:
Duration:
Characteristics:
Aggravating Factors:
Relieving Factors:
Treatment:
Current Medications:
PMH
Allergies
Medication Intolerances:
Chronic Illnesses/Major traumas:
Screening Hx/Immunizations Hx:
Hospitalizations/Surgeries:
Family History:
Social History:
ROS
General:
Skin, hair, nails:
Eyes:
Ears:
Nose/Mouth/Throat:
Breast:
Cardiovascular:
Respiratory:
Heme/Lymph/Endo:
Gastrointestinal:
Genitourinary/Gynecological:
Musculoskeletal:
Neurological:
Psychiatric:
Race:
SOAP NOTE
OBJECTIVE
Weight
BMI
Height
PHYSICAL EXAMINATION
General Appearance:
Skin and nails:
HEENT:
Breast:
Cardiovascular:
Respiratory:
Heme/Lymph/Endo:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Lab Tests:
Temp
Pulse
BP
Resp
SOAP NOTE
Special Tests:
DIAGNOSIS
•
Primary Diagnosis▪ Evidence for primary diagnosis should be documented in your Subjective and
Objective exams.
•
Differential Diagnoses▪ Must provide three (3) differential diagnoses with one citation for each diagnosis.
PLAN – TREATMENT – EDUCATION
Plan:
▪ Further testing, Labs, exams.
▪ Medications
▪ Non-medication treatments
▪ Education
Referrals:
Follow – up visits:
References (Minimum 3 references)
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