homework

PRIMARY CARE SOAP NOTE

PRIMARY CARE SOAP NOTE

PRIMARY CARE SOAP NOTE

Student: __________________________ Date: ______________

Professor: ______________________________________________________________

PATIENT INFORMATION:

NAME: ______________________________________________________________________

AGE: ______________SEX: _______________

CC:__________________________________________________________________________

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SUBJECTIVE:

HPI:_________________________________________________________________________

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ALLERGIES:

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CURRENTMEDICATIONS_____________________________________________________

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PMHX:_______________________________________________________________________

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FAMH:_______________________________________________________________________

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SOCHX:______________________________________________________________________

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REVIEW OF SYSTEMS:

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HEENT:

HEAD:_______________________________________________________________________

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EYES:________________________________________________________________________

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EARS:_______________________________________________________________________

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NOSE:_______________________________________________________________________

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THROAT:____________________________________________________________________

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RESPIRATORY:

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GASTROINTESTINAL:

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GENITOURINARY:

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MUSCULOSKELETAL: _______________________________________________________

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NEUROLOGIC:_______________________________________________________________

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______________________________________________________________________________ ______________________________________________________________________________ OBJECTIVE:

CONSTITUTIONAL:

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SKIN:

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HEENT:

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NECK:

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RESPIRATORY:

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CARDIOVASCULAR:

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GASTROINTESTINAL:

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______________________________________________________________________________ GENITOURINARY:

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PERIPHERAL VASCULAR:

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MUSCULOSKELETAL:

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NEUROLOGIC:

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ASSESSMENT:

DIAGNOSIS:

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DIFFERENTIAL DIAGNOSIS:

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______________________________________________________________________________ ____________________________________________________________________________ PLAN:

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Non-Pharmacologic treatment:

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______________________________________________________________________________ Pharmacologic treatment:

MEDICATIONS:

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FOLLOW-UPS/REFERRALS:

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______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ RATIONALE:

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