MEdical Notas

Soap Note 2 Acute or Chronic Conditions

1-Pick “ONLY ONE “ "ADULT" Acute or Chronic Disease from the list given below:

Diseases and Disorders of the Gastrointestinal System

 Appendicitis

 Cirrhosis

 Colitis

 Crohn's Disease

 Hepatitis

 Irritable Bowel Syndrome (IBS)

 Pancreatitis

Diseases and Disorders of the Renal/GU System

 Acute Kidney Injury (AKI)

 Prostate Cancer

 Prostatic Hyperplasia, Benign (BPH)

 Pyelonephritis

 Urinary Tract Infection (UTI)

DiseasesandDisordersofthe Endocrine System

 Addison Disease

 Cushing Syndrome

 Diabetes

 Graves' Disease

 Hyper-, Hypoparathyroidism

 Hyper-,Hypothyroidism

 Myasthenia Gravis

1- Must use the sample template attached as a reference for your soap note, and filling all the point as indicated and highlighter in the template.( not forget the ICD-10-CM diagnosis Code ,education , medication, follow up, referral to specialist if needed)

2- Follow the MRU Soap Note Rubric as a guide. Please Read and follow instructions as it stated.

3- Must use APA format and must include minimum of 3 Scholarly Citations.

4- Turn it in Score must be less than 15% or will not be accepted, must be your own work and in your own words.

5- The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to the patient.

6- I am attaching a SOAP NOTE without template to use as an idea of the contains . IS not needed to do a SOAP NOTE as long as it is, the Important is that all the point requested are in the SOAP NOTE and well develop .

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