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Mario is a 66-year-old Hispanic male The Assignment: Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following: • Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a […]
Mental Status Exam Guide Previous Mental Health Treatments: Please provide details of any previous mental health treatments, including psychopharmacology, inpatient stabilization, occupational therapy, vocational therapy, marriage/family therapy, group therapy, detoxification, electroconvulsive therapy (ECT), and social services. Initial Impression: What is the initial impression of the admitting examiner found in the initial evaluation, triage, or social […]
Discussion Topic: Soap Note: Scabies Requirements – The discussion must address the topic – Rationale must be provided mainly in the differential diagnosis, and it must have at least 3 differential diagnosis. – Use at least 600 words (no included 1st page or references in the 600 words) – May use examples from your nursing […]
Psychiatric SOAP Note Template Encounter date: ______17/05/2023__________________ Patient Initials: ___G.W.___ Gender: M/F/Transgender _Male___ Age: __15___ Race: ___Caucasian__ Ethnicity __White__ Reason for Seeking Health Care: “For the past three weeks, my son has been quite depressed. He has not been eating well and prefers to spend his after-school hours alone in his room. He used to […]
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 […]
Discussion Topic: Soap Note 1 “Urinary Tract Infection” Requirements Soap Note # ____ Main Diagnosis ______________ PATIENT INFORMATION Name: Age: Gender at Birth: Gender Identity: Source: Allergies: Current Medications: • PMH: Immunizations: Preventive Care: Surgical History: Family History: Social History: Sexual Orientation: Nutrition History: Subjective Data: Chief Complaint: Symptom analysis/HPI: The patient is … Review […]
Soap Note # ____ Main Diagnosis ______________ PATIENT INFORMATION Name: Age: Gender at Birth: Gender Identity: Source: Allergies: Current Medications: • PMH: Immunizations: Preventive Care: Surgical History: Family History: Social History: Sexual Orientation: Nutrition History: Subjective Data: Chief Complaint: Symptom analysis/HPI: The patient is … Review of Systems (ROS) (This section is what the patient […]
Soap Note # ____ Main Diagnosis ______________ PATIENT INFORMATION Name: Age: Gender at Birth: Gender Identity: Source: Allergies: Current Medications: • PMH: Immunizations: Preventive Care: Surgical History: Family History: Social History: Sexual Orientation: Nutrition History: Subjective Data: Chief Complaint: Symptom analysis/HPI: The patient is … Review of Systems (ROS) (This section is what the patient […]
SOAP Note # _____ Main Diagnosis: Herpes Zoster PATIENT INFORMATION: Name: Ms. GP Age: 78 Gender at Birth: Female Gender Identity: Female Source: Patient Allergies: Peanut, Iodine Current Medications: Insulin Lantus 100 u/ml 15 unit in the morning and at bedtime Metformin 500 mg 1 tablet PO once a day Atorvastatin 20 mg 1 tablet […]
Soap Note # ____ Main Diagnosis ______________ PATIENT INFORMATION Name: Age: Gender at Birth: Gender Identity: Source: Allergies: Current Medications: • PMH: Immunizations: Preventive Care: Surgical History: Family History: Social History: Sexual Orientation: Nutrition History: Subjective Data: Chief Complaint: Symptom analysis/HPI: The patient is … Review of Systems (ROS) (This section is what the patient […]
