4 different SOAP NOTES 1-UTI, 2- DIABETES TYPE 2, 3-Hypertension. 4- Psoriasis. Form attached

Soap Note # and Diagnosis

Student Name

Miami Regional University

Course Number

Date of Encounter

Preceptor Name/Clinical Site

Faculty Instructor Name

SOAP Note # and Diagnosis

PATIENT INFORMATION

Name: Only abbreviations, no real names (HIPPA violation)

Age:

Gender at Birth:

Gender Identity:

Source: Patient or family member

Allergies:

Current Medications:

List name, dose and frequency

Past Medical History:

Immunizations:

Preventive Care: last wellness exam ?

Surgical History:

Family History:

Social History:

Sexual Orientation:

Nutrition History:

SUBJECTIVE DATA

Chief Complaint: “Must be in patient’s own words.”

Symptom analysis/HPI:

Review of Systems (ROS)

Constitutional:

Neurologic:

HEENT:

Respiratory:

Cardiovascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Skin:

Hemo/Lymph/Endocrine:

Behavioral Health:

OBJECTIVE DATA

Vital Signs

Weight:

Height:

BMI:

BP:

HR:

RR:

Temperature:

Pain:

Physical Examination

General Appearance:

Neurologic:

HEENT:

Eyes:

Ears:

Nose:

Mouth:

Neck:

Cardiovascular:

Respiratory:

Gastrointestinal:

Musculoskeletal:

Integumentary:

ASSESSMENT

Begin your description of what you believe the diagnosis is and the rationale for the assessment. Be sure to include references based on the presentation and current guidelines.

Main Diagnosis

Diagnosis (ICD-10 code): include reference for diagnosis here with (in-text citation).

Differential diagnoses

condition (ICD-10 code):

PLAN

Labs and Diagnostic Tests to be ordered (if applicable):

Pharmacological treatment:

Non-Pharmacologic treatment:

Education:

Follow-ups/Referrals:

Next appointment etc

References

Example: Last name, First initial. (year). Title. Publisher.

***Hanging indent is required for reference page (please see APA 7th edition for proper references format.