CLINICAL CASE
Mechy19
FNUSampleSOAPNote.rtfPatient Initials:
Pt. Encounter Number:
Date:
Age:
Sex:
Allergies: Advanced Directives:
SUBJECTIVE
CC: Reason given by the patient for seeking medical care “in quotes”
HPI: Describe the course of the patient’s illness: Onset: Location: Duration: Characteristics: Aggravating Factors: Relieving Factors: Treatment:
Current Medications: (List with reason for med)
PMH Medication Intolerances: Chronic Illnesses/Major traumas Screening Hx/Immunizations Hx: Hospitalizations/Surgeries: “Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”
Family History Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?
Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status
OBJECTIVE
Weight BMI
Temp
BP
Height
Pulse
Resp
Oxygen Saturation
Lab Tests
Urinalysis—pending Urine culture—pending Wet prep—pending
Special Tests
Diagnosis
- • Primary Diagnosis- Include at least three diagnoses ♣ Evidence for primary diagnosis should be documented in your Subjective and Objective exams. • Secondary Diagnosis- if apply, chronic diseases can be included as secondary diagnosis o Differential Diagnoses- provide at least three differential diagnosis supported by signs and symptoms explaining why these are not your primary diagnosis PLAN including education o Plan: ♣ Further testing ♣ Medication ♣ Education ♣ Nonmedication treatments ♣ Referrals ♣ Follow-up visits
References (minimum 3 references) APA FORMAT JUST REFERENCES
