Soap 3

SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive SOAP note is to be written using

With your instructor’s permission, you may write an episodic SOAP note in place of the comprehensive. The episodic SOAP note is to be written using the attached template below.

For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:

S =Subjective data: Patient’s Chief Complaint (CC).O =Objective data: Including client behavior, physical assessment, vital signs, and meds.A =Assessment: Diagnosis of the patient’s condition. Include differential diagnosis.P =Plan: Treatment, diagnostic testing, and follow up

Submission Instructions:

  • Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.Text  Description automatically generated with medium confidence

     

    Episodic Women’s Health SOAP Note Template

     

     

    Encounter date:

     

    Patient Initials: Gender: Age: Race/Ethnicity:

     

    Subjective

     

    Reason for Seeking Health Care:

     

    History of Present Illness (HPI):

     

    Allergies (Drug/Food/Latex/Environmental/Herbal):

     

    Current Medications (including over the counter medications):

     

    Past Medical History (PMH):

     

    OB/GYN History:

     

    Past Surgical History:

     

    Family Medical History:

     

    Social History:

     

    Review of Systems (ROS)

    Focus on systems affecting women’s health and inquire about systems relevant to the reason for the visit)

     

    Physical Examination

    Vital Signs

    General Appearance

    Include physical exam of all relevant systems based on the reason for the visit and the HPI. Perform a cardiopulmonary exam on all patients regardless of the reason for seeking care.

     

    Significant Data/Contributing Dx/Labs/Misc

     

     

     

     

     

     

    Assessment

    Differential Diagnoses (3 minimum)

    Primary Diagnoses

     

    Plan

    For each primary diagnosis, include laboratory/diagnostic tests, therapeutic/pharmacological therapy, referrals, and follow-up ordered and patient education done for this visit.

    Include age-appropriate health promotion/maintenance/screening needs.

     

    Remember that for every S (reason for the visit), there must be an O, A, and P (relevant exam, diagnosis, and plan). Always sign your notes.

     

    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: ____________________________________________________________

     

     

     

    Signature (with appropriate credentials): __________________________________________

     

    References (must use current evidence-based guidelines used to guide the care [Mandatory])

     

     

     

    5

    Joseph, M. V. (2021). Episodic Women’s Health SOAP Note. Copyright ©

    Text  Description automatically generated with medium confidence

     

    Comprehensive Women’s Health History and Physical Template

     

     

    Encounter date:

     

    Patient Initials: Gender: Age: Race/Ethnicity:

     

    Reason for Seeking Health Care

     

    History of Present Illness (HPI)

     

    Allergies (Drug/Food/Latex/Environmental/Herbal)

     

    Current Perception of Health

     

    Current Medications (including over the counter)

     

    Menstrual History

    Age at Menarche

    Last menstrual period

    Menstrual Pattern

    Cycle Length

    Duration of Flow

    Amount of Flow

    Bleeding Pattern

    Break through Bleeding

     

    Gynecologic History

    History of breast disease, breast feeding, use of self-breast exam, last mammogram (if applicable)

    Previous GYN surgery (may include that in surgical history)

    History of infertility

    History of diethylstilbestrol (DES) use by patient’s mother

    Last pap smear, history of abnormal pap

     

    Pre-menopause/menopause

    Vasomotor symptoms

    Hormone Replacement Therapy

     

    Sexual and Contraceptive History

    Current method of contraception

    Sexually active

    Number of sexual partners

    New partners in the 3-6 months

    Condom use

    History of sexual abuse

    History of sexually transmitted infections (STIs)

     

    Obstetric History (including complications)

     

    Past Medical History (PMH)

    Major/Chronic Illnesses

    Trauma/Injury

    Hospitalizations

     

    Past Surgical History

     

    Family Medical History

     

    Social History

    Living condition

    Marital status

    Education

    Employment

    Occupation

    Social supports

    Habits (smoking, alcohol use and illicit drugs use)

     

    Health Maintenance

    Age-appropriate health promotion/maintenance and screening history

    Immunization history

     

    Review of Systems (ROS)

    General

    Dermatology

    HEENT

    Neck

    Pulmonary System

    Cardiovascular System (CVS)

    Breast

    Gastrointestinal (GI) System

    Genitourinary (GU) System

    Female Genitalia

    Musculoskeletal System

    Neurological System.

    Endocrine

    Psychologic

    Hematologic/Lymphatic

     

    Physical Examination

     

    Vital Signs

    Blood Pressure (BP: Temperature Heart Rate (HR) Respiratory Rate (RR)

    Height Weight Body Mass Index (BMI) Pain

     

    General Appearance

    Dermatology

    HEENT

    Neck

    Pulmonary System

    Cardiovascular System (CVS)

    Breast

    Gastrointestinal (GI) System

    Genitourinary (GU) System

    Female Genitalia

    Musculoskeletal System

    Neurological System.

    Endocrine

    Psychologic

    Hematologic/Lymphatic

     

    Significant Data/Contributing Dx/Labs/Misc

     

     

     

     

     

     

    Assessment

    Differential Diagnoses (3 minimum)

    Primary Diagnoses

     

    Plan (For each primary diagnosis, include laboratory/diagnostic tests, therapeutic/pharmacological therapy, referrals, and follow-up ordered and patient education done for this visit)

    Diagnoses

    Laboratory/Diagnostic Studies

    Therapeutic (Non-pharmacological interventions)

    Pharmacological Therapy

    Patient Education/Anticipatory Guidance

    Referrals

    Follow up

     

    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: ____________________________________________________________

     

     

     

    Signature (with appropriate credentials): __________________________________________

     

    References (must use current evidence-based guidelines used to guide the care [Mandatory])

     

     

     

    5

    Joseph, M. V. (2021). Women’s Health Comprehensive H & P. Copyright ©

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