MN605 Discussion 5
Documentation SOAP Note
Create a focused exam SOAP note based on a case during your clinicals. This same case will be used for your Unit 6 presentation video. References should be guidelines that support the treatment plan and related condition/s.
Subjective
- Opener presentation of the patient (age/sex/presentation of issue with key past DX)
- History of present illness (HPI) (OldCarts)
- Other related past medical history
- Review of systems (ROS)
Objective
- Vital signs and physical exam on pertinent body systems
Assessment
- Assessment including differentials and specific labs or X-rays reviewed
Plan
- Explain the plan that you are suggesting or that was done, including any education, further work-up, specific medications with doses and frequency, consultations/referral, and follow-up.
