Episodic/Focused Note: Musculoskeletal Focused Note Assignment Example Patient Information: Initials: J.S. Age: 52 Sex: Female Race: Caucasian S. (Subjective) CC: “My right knee has been hurting for weeks.” HPI: A 52-year-old Caucasian female presents with a chief complaint of right knee pain for the past 6 weeks. The pain is described as a dull ache […]
Case Study: Migraine Headaches in a 19-Year-Old Female Migraine headaches are a common neurological condition that can significantly impact the quality of life. This case study examines a 19-year-old female presenting with frequent headaches, exploring the clinical presentation, assessment, and management strategies. The aim is to provide a comprehensive understanding of migraine diagnosis and treatment, […]
WCU Adult Gero SOAP Note Template Use this template for Comprehensive Notes (Initial Comprehensive/Annual visit) and Problem-Focused Notes (Episodic/progress notes). For the Problem-Focused Notes, only include pertinent problem-focused information related to the chief concern (CC). Demographic Data o Patient age and gender identity o MUST BE HIPAA compliant Subjective Chief Complaint (CC) O Place the […]
Focused SOAP Note for a patient with chest pain S: CC: “Chest pain” HPI: The patient is a 65 year old AA male who developed sudden onset of crushing chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain […]
Focused SOAP Note Patient Information: D, 72-years old female. S. Chief Complaint (CC): Debilitating headache and neck pain HPI: Dickson is a 72-year old female who comes to the clinic with a debilitating headache and neck pain. The patient complains that the problem is not new, but has worsened in the last week and currently […]
