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Posted: December 30th, 2021

Week 10 SOAP NOTE essay

SOAP NOTE

Title: EC

Date:

Time:

Age: 47 years

Intercourse: Feminine

SUBJECTIVE

CC: I’ve been having ache in my pelvis space for the previous month, my final menstrual durations was 7 month in the past however I’ve been recognizing.

HPI: (Use OLD CARTS instrument)

Medicines:

PMH:

Allergic reactions:

Medicine Intolerances:

Immunizations:

Continual Diseases/Main traumas:

Hospitalizations/Surgical procedures (embody supply of pregnancies right here)

Household Historical past

Social Historical past

ROS

Normal

Cardiovascular

Pores and skin

Respiratory

Eyes

Gastrointestinal

Ears

Genitourinary/Gynecological

Nostril/Mouth/Throat

Musculoskeletal

Breast

Neurological

Heme/Lymph/Endo

Psychiatric

OBJECTIVE

Weight: BMI:

Temp:

BP:

Peak:

Pulse:

Resp:

Normal Look

Pores and skin

HEENT

Cardiovascular

Respiratory

Gastrointestinal

Breast

Genitourinary

Musculoskeletal

Neurological

Psychiatric

Lab Exams (record the outcomes when you’ve got them)

Particular Exams (achieved or ordered in the course of the OV)

No particular checks ordered.

Analysis – embody the suitable ICD – 10 Code for every analysis used

Major Analysis

Differential Diagnoses (these have to be totally different from the Major Analysis)

Plan/Therapeutics (clarify absolutely)

Analysis of affected person encounter

References

1

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