Our Services

Get 15% Discount on your First Order

[rank_math_breadcrumb]

advice health

I need your expertise 

SOAP Note Template

Encounter date: ________________________

Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

Reason for Seeking Health Care: ______________________________________________

HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________

Current perception of Health: Excellent Good Fair Poor

Past Medical History

· Major/Chronic Illnesses____________________________________________________

· Trauma/Injury ___________________________________________________________

· Hospitalizations __________________________________________________________

Past Surgical History___________________________________________________________

Medications: __________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Family History: ____________________________________________________________

Social history:


Lives: Single family House/Condo/ with stairs: ___________
Marital Status:________
Employment Status: ______
Current/Previous occupation type: _________________

Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________

Sexual orientation: _______ Sexual Activity: ____
Contraception Use: ____________

Family Composition: Family/Mother/Father/Alone
: _____________________________

Health Maintenance

Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____

Exposures:

Immunization HX:

Review of Systems:

General:

HEENT:

Neck:

Lungs:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Activity & Exercise:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

Physical Exam

BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
percentile) _____

General:

HEENT:

Neck:

Pulmonary:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Derm:

Psychosocial:

Misc.



Significant Data/Contributing Dx/Labs/Misc.

Plan:

Differential Diagnoses

1.

2.

3.

Principal Diagnoses

1.

2.

Plan

Diagnosis

Diagnostic Testing:

Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

Diagnosis

Diagnostic Testing:

Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

Signature (with appropriate credentials): __________________________________________

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________

DEA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age ___________

Date: _______________

RX ______________________________________

SIG:

Dispense: ___________
Refill: _________________

No Substitution

Signature: ____________________________________________________________

Copyright © MVJ 2018

image1.png

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

nursing

Briefly describe your selected recent natural disaster. Discuss the health consequences of the disaster at the population level. Explain how the concepts of population health and epidemiology discussed in this course were or could have been used to assess the preparation and health outcomes after this disaster. Explain how the

nursing

Read a selection of your colleagues’ posts and respond to at least two of your colleagues on two different days by supporting or expanding on the ideas identified by your colleague or sharing additional perspectives on the issue described by your colleague.

nursing

Post a response detailing the following:  How has this course impacted your knowledge, attitude, beliefs, perceptions about nurse engagement in policy advocacy and politics? What are the takeaways as you move forward as a DNP, in your role as a policy advocate? What resonates with you and how will you

Anesthesia Poster

Topic: Monitoring Exhaled Air to Measure Anesthesia Depth POSTER TITLE Clinical Question Practice Problem Project Description Conclusions References Name, Credentials DNAP Student Email Address Project Evaluation Nursing and Healthcare Implications 1 image1.jpg

Nursing week 11 assignment

question is attached To Prepare: · Review the World Health Organization’s (WHO) global health agenda and select one global health issue to focus on for this Assignment. · Select at least one additional country to compare to the U.S. for this Assignment. · Reflect on how the global health issue

Global Environmental Issues

Homework Help MUST BE ORIGINAL WORK ONLY- must write 5-sentence paragraphs (or more) and you must use outside resources (refer to them in text and include the citation) to receive full credit. DB 3 – Critical Concerns CURRENT Events We are now entering the section of this course where we

Gerontology Weekly Clinical Experience 3

Weekly Clinical Experience 3 Describe your clinical experience for this week with at 70-year-old patient with high cholesterol · Did you face any challenges, any success? If so, what were they? · Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at

Gerontology Discussion 3

Discussion 3 A 72-year-old male presents to the clinic with 4 weeks of productive cough. He has a 10-year history of diagnosed COPD. He has a 45-year history of two packs a day cigarette smoking. He states he quit smoking due to financial needs about 6 years ago. He complains

week 3 discussion 3-patho

Discussion 3 Pulmonary Function: D.R. is a 27-year-old man, who presents to the nurse practitioner at the Family Care Clinic complaining of increasing SOB, wheezing, fatigue, cough, stuffy nose, watery eyes, and postnasal drainage—all of which began four days ago. Three days ago, he began monitoring his peak flow rates

module 3 discussion 3-What makes a team?

What makes a team? Reflect on your experiences as a member of a clinical team. What makes a team effective or ineffective in terms of achieving expected outcomes for the patients? (Saunders, 2014)   Submission Instructions: · Your initial post should be at least 500 words, formatted and cited in current

What makes a team?

Reflect on your experiences as a member of a clinical team. What makes a team effective or ineffective in terms of achieving expected outcomes for the patients? (Saunders, 2014)

Nursing Role of a Nurse Practitioner assignment

Role of a Nurse Practitioner Research the role of the Nurse Practitioner.   1. Select and describe an Advanced Nurse Practitioner role.  2. Why are you becoming a Nurse Practitioner? 3. Find one research article, expert opinion about the Nurse Practitioner role and summarize the article.  4. What does the Institute Of Medicine (IOM)

assigment instrucction attached

Module 3:  Emerging Disease After studying the module material, answer the following questions: 1.    Choose a current emerging disease or reemerging disease prevalent in your community or the larger community of the nation or world.  2.    Complete an epidemiology triangle diagram for the chosen disease and thoroughly describe,

assigment instrucction attached

Assignment Types of Research in Healthcare Include submission instructions for the assignment. The instructions should be clear and precise and cover all the information needed in order for the student to be successful in accomplishing objectives. Include related material, links, or attachments. Make sure there is a topic as well

assgnt 6

Reflect on the four peer-reviewed articles you critically appraised in Module 4, related to your clinical topic of interest and PICOT.

Nursing homework1

Please answer as a family nurse practitioner student Watch the videos on the  Gender dysphoria page giving opposing views on the issue/treatment of early adolescent/adolescent gender dysphoria.  · Gender Spectrum documentary · Man, Woman & The Order of Creation · Trans Kids: The medical Scandal · DeTrans: The Dangers of Gender

week 10

 Concepts of Women and Men’s Health Emily B. is a 19-year-old Caucasian college sophomore who presents to the student health clinic for evaluation of increased vaginal discharge, occasional pelvic discomfort, and mild dysuria over the past week. She denies fever, chills, or abnormal bleeding. She became sexually active at 17

Student Learning Outcome

Patients’ information: Pt 1: Primary Diagnosis (PD): Non–Non-ST-Elevation Myocardial Infarction (NSTEMI) Comorbidities: AKI, Asthma, COPD, seizure, Depression, Anxiety, CAD, Caffeine abuse, and hypercholesterolemia Pt 2: Primary Diagnosis (PD): Suspected conversion disorder Comorbidities: Bilateral lower extremity weakness, PTSD, and ADH Please, for the Gordon assessment, use patient 1, who is a