Week 6 SOAP NOTE

Name: 

Date:

Time:

Age: 27 years

Sex: Female

SUBJECTIVE

CC:  My periods is 22 days, I have pelvic pain and also noted some dark vaginal bleeding since yesterday.

HPI:  (Use OLD CARTS tool)

Medications:

PMH:

Allergies:  

Medication Intolerances:

Immunizations:

Chronic Illnesses/Major traumas:

Hospitalizations/Surgeries (include delivery of pregnancies here)

Family History

Social History

ROS

General

Cardiovascular

Skin

Respiratory

Eyes

Gastrointestinal

Ears

Genitourinary/Gynecological

Nose/Mouth/Throat

Musculoskeletal

Breast

Neurological

Heme/Lymph/Endo

Psychiatric

OBJECTIVE

Weight: BMI:

Temp:

BP:

Height:

Pulse:

Resp:

General Appearance

Skin

HEENT

Cardiovascular

Respiratory

Gastrointestinal

Breast

Genitourinary

Musculoskeletal

Neurological

Psychiatric

Lab Tests (list the results if you have them)

Special Tests (done or ordered during the OV)

No special tests ordered.

 Diagnosis – include the appropriate ICD – 10 Code for each diagnosis used

Primary Diagnosis

Differential Diagnoses (these must be different from the Primary Diagnosis)

Plan/Therapeutics (explain fully)

 Evaluation of patient encounter