SOAP NOTE
Title: EC
Date:
Time:
Age: 47 years
Intercourse: Female
SUBJECTIVE
CC: I have been having ache in my pelvis house for the earlier month, my closing menstrual durations was 7 month up to now nevertheless I have been recognizing.
HPI: (Use OLD CARTS instrument)
Medicines:
PMH:
Allergic reactions:
Medication Intolerances:
Immunizations:
Continuous Ailments/Most important traumas:
Hospitalizations/Surgical procedures (embody provide of pregnancies proper right here)
Family Historic previous
Social Historic previous
ROS
Regular
Cardiovascular
Pores and 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:
Regular Look
Pores and pores and skin
HEENT
Cardiovascular
Respiratory
Gastrointestinal
Breast
Genitourinary
Musculoskeletal
Neurological
Psychiatric
Lab Exams (report the outcomes whenever you’ve bought them)
Specific Exams (achieved or ordered in the middle of the OV)
No specific checks ordered.
Assessment – embody the acceptable ICD – 10 Code for each Assessment used
Main Assessment
Differential Diagnoses (these should be completely totally different from the Main Assessment)
Plan/Therapeutics (make clear completely)
Assessment of affected individual encounter
References
1
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