Week 7 DB post

SOAP NOTE FORMAT

Subjective

CC:

HPI:

Medications:

Allergies:

LMP:

Gyn/OB history:

PMH:

Chronic Illness/ Major trauma:

Family Hx:

Social Hx:

ROS

- List the body systems and provide answers

- (Don’t forget to include Gyn ROS)

- You can include questions here that you’d like to ask the patient

Objective Data

General- provide findings

VS

List body systems- provide findings

- (Don’t forget Gyn System)

- (You can include answers here to questions posed in the prompt)

Include POCT (Point of Care testing) not labs that you will send to the laboratoryAssessment/

DiagnosisInclude the ICD10 code

DDX

Plan

Diagnostic tests

Lab Tests

Treatment

Medication

Referrals

Education

Health Maintenance

Follow up

Prompt Questions

(You can include answers here that is asked in the prompt)