SOAP note templateee

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Los Angeles Pierce College *

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663

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Medicine

Date

Dec 6, 2023

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docx

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Uploaded by lian.canon

Adhere to the following SOAP format on all your clinical case studies: SUBJECTIVE: HPI PMHx FHx SHx Medications ROS OBJECTIVE: Vitals with BMI Constitutional HEENT Cardiac Pulmo GI Musculoskeletal Skin GU - if relevant  Always provide a very detailed physical exam, or description of what you want to elicit on your physical exam on the organ system involved in your chief complaint ASSESSMENT: Working Diagnosis - provide ICD 10 codes - provide rationales or pertinent positives and negatives that made you consider the diagnosis

Differential # 1 - diagnosis you cannot miss. - rationale why it can't be missed - provide ICD 10 code Differential # 2 - what else could it be? - rationale why you ruled it out -provide ICD 10 Code PLAN  Diagnostics  Pharmacological Plan - indicate dosage and regimen, if not indicated state accordingly  Health Education Plan  Referral Plan - if not indicated, state accordingly  Follow-up plan - indicate when patient needs to follow-up and what symptoms to watch out for  Health promotion plan - age-specific health promotion recommendations not related to the case per USPTF REFERENCES

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