pleasant 57-year-old female who presents to the clinic to establish care.C/O Fatigue The patient has a h/o thyroid disease and takes medication for this. . She does take supplements . Is UTD on pap smear . She also has OA bladder and takes medication successfully for this. PMH overactive bladder and hypothyroidism. long term use of drug therapy. BMI 30
Patient is due for labs.
Please references less than 5 years
TYPE OF SOAP NOTE well visit establish care.
DATE
SOAP Note
CC:
HPI:
Allergies:
Social History:
Medications:
Past Surgical History:
Family History:
ROS:
General:
Skin:.
Head:
Eyes:
Ears:
Nose/ Sinus:
Mouth/ Throat:
Neck:
Pulmonary:
Cardiac:
GI:
Urinary:
Peripheral Vascular:
Musculoskeletal:
Neuro:
Heme:
Endo:
Psych:
Objective:
Vital Signs: BP: , HR: , RR: , Temp: , BMI (normal/overweight)
General:
Skin:
HEENT:
Neck & Lymph:
Thorax & Lungs
CV:
Abdomen:
Musculoskeletal:
Neuro:
Psychiatric:
In office lab results/Point of care testing:
Assessment/Diagnosis: (include your rationale)
1. ICD10 code + diagnosis + rationale
2. ICD10 code + diagnosis + rationale
Plan: Diagnostics
1. Order labs: (List labs and rationale why for each lab ordered)
2. Order Imaging: (List what tests would you order and why)
2. Referrals:
Plan: Intervention
1. (List appropriate therapeutic interventions (pharm & non-pharm) based on current evidence) Include medication, name, dose, number given, route, frequency, length of time and number of refills prescribed for all medications. Include orders for referral to other therapeutic modalities.
Plan: Education
–
–
–
–
Plan: Follow up
1.
2.
3.
3 Differential Diagnosis + Pathophysiology + Rationale for accepting or rejecting diagnoses.
1. ICD10 code – Diagnosis
– Pathophysiology:
– Rationale:
2. ICD10 code – Diagnosis
– Pathophysiology
– Rationale:
3. ICD10 code – Diagnosis
– Pathophysiology
– Rationale:
4. Next steps (Based upon the pathophysiology of the diagnosis and expected findings from the literature, indicate if additional history, exam, diagnostics/ labs/or time are yet needed to make a firm diagnosis).
5. Discussion
1.
Guideline Selection and Comparison
Guidelines used for this visit:
Reflection:
Inter-professional POC:
Last Completed Projects
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