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SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. S = Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS) O = Objective […]
1 Page Case discussion: Main Diagnosis: Impetigo Differential diagnosis: 1- Herpes simplex 2- Varicella 3- Contact dermatitis References: within the Last 5 years Case Discussion SOAP Note ___________________________- Patient: [Patient’s Name] Date: [Date of Examination] Age: [Patient’s Age] Gender: [Patient’s Gender] Medical Record Number: [MRN] S: The patient presents with a skin rash characterized by […]
Episodic/Focused SOAP Note Template Patient Information: Initials, Age, Sex, Race S. CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”. HPI: This is the symptom analysis section of your note. Thorough documentation in this section is […]
NRNNP 6552 Reproductive Health. Candida Albicans or Polycystic Ovarian Syndrome Focus SOAP Note Assignment: Subjective: What details did the patient provide regarding her personal and medical history? Objective: What observations did you make during the physical assessment? Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority […]
Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations. Review the video, Case Study: Sherman Tremaine. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is […]
S: CC (Chief Complaint): Abdominal pain and bloating HPI (History of Present Illness): The patient, a 32-year-old female, presents with a complaint of abdominal pain and bloating for the past 5 days. She describes the pain as dull and aching, mostly located in the lower abdomen, but also present in the upper and mid-abdomen. The […]
Patient Information: JF, a 32-year-old female, presents with complaints of fever, cough, and shortness of breath. S. CC (chief complaint): Fever, cough, and shortness of breath. HPI: JF reports feeling unwell for the past week, with symptoms that started as a mild cough and progressed to fever and shortness of breath. She describes her cough […]
Patient Information: RM, a 45-year-old male, presents with acute chest pain. S. CC (chief complaint): Acute chest pain. HPI: RM reports sudden onset of chest pain while at rest. The pain is located in the center of his chest and feels like pressure or tightness. He describes it as an 8 out of 10 in […]
