?Assignment SOAP Note

Assignment SOAP Note Purpose Documenting, using the standard SOAP note for clinical encounters, ensures that the patient is fully assessed. The SOAP note is a best practice and is universally accepted as the documentation method for clinical encounters. Directions For this Assignment, you are to complete a SOAP note for a patient that you have assessed in clinical. Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with cough and cold symptoms, you would examine the general appearance, HEENT, neck, heart, and lungs for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice. The only section that will not be included in a real chart is differential diagnosis. Remember that the differential diagnosis list includes the diagnosis you are considering. The term “Rule Out…” cannot be used as a diagnosis. Assignment Requirements Before finalizing your work, you should: be sure to read the Assignment description carefully (as displayed above);utilize spelling and grammar check to minimize errors.Your writing Assignment should:follow the conventions of Standard American English (correct grammar, punctuation, etc.);be well ordered , logical, and unified, as well as original and insightful;display superior content, organization, style, and mechanics; anduse APA 6th Editionreferences less than 5 years old at least 3-5See attach file
soap_template.docx

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Running head: TITLE GOES HERE
1
Title of Paper Here
Student Name
Course Name
Instructor Name
Date
TITLE OF PAPER HERE
SUBJECTIVE
Chief Complaint (CC):
History of Present Illness (HPI):
Last Menstrual Period (LMP — if applicable):
Allergies:
Past Medical History:
Family History:
Surgery History:
Social History:
Current medications:
Review of Systems (ROS)
Constitutional:
HEENT:
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
2
TITLE OF PAPER HERE
Psychiatric:
OBJECTIVE
Vital Signs/Height/Weight/BMI/Percentiles:
General Appearance:
HEENT:
Neck:
Cardiovascular:
Respiratory:
Abdomen:
Genitourinary:
Extremities:
Back/Hips:
Musculoskeletal:
Dermatologic:
Psychiatric:
Neurological:
ASSESSMENT
A: Differential diagnoses with cited rationale (list at least 3)
1.
2.
3.
B: Medical diagnosis with cited rationale (list at least 1)
1.
3
TITLE OF PAPER HERE
4
PLAN
Orders (replace text in 1–5 below with your content)
1. Prescriptions with dosage, route, directions to administer, amount to be dispensed, and any
refills
2. Diagnostic testing
3. Problem-oriented education
4. Health promotion/maintenance needs/psychosocial needs
5. Referrals
Patient/Family Education:
Cultural Considerations:
Follow-Up Plans (replace text in 1–3 below with your content)
1. Return to clinic (RTC) in what time frame and reason for next visit
2. Interventions considered if not improved
3. Next health maintenance visit due
TITLE OF PAPER HERE
5
TITLE OF PAPER HERE
6
References
Author, A. B., & Author, C. D. (year). Title of reference. Where located. This is the basic
formula for all reference entries. The following are some examples.
Able, E. F., Cain, J. K., & Daniels, L. M. (year). Title of webpage/article, if article. Retrieved
from URL [Note, no period at end of this kind of entry]
Boyer, R. M. (year). Title of journal article. Title of Journal, volume number, (issue number),
pages numbers of article.
Elephant, N. O. (year). Title of chapter. In P. Q. Frank & R. S. Grant (Eds. [if listed as editor on
book; leave off if not]), Title of book here (3rd ed. [if edition number present], pp. XX–
YY). City, STATE ABBREVIATION: Jones and Bartlett [Note, no “Publisher” or other
words used].
Higgs, T. U. (year). Title of book (edition number, if one, as: xth ed.). City, STATE: Publisher.
Johnson, X. Y. (year, month day). Title of video [Video file]. Retrieved from URL

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