03 Sep Using the sample template uploaded create a SOAP note of a female patient of 33 years old who comes to primary care consult with UTI symptoms, include differe
Using the sample template uploaded create a SOAP note of a female patient of 33 years old who comes to primary care consult with UTI symptoms, include differential diagnosis, patient education. Use APA 7 format and scholarly references no older than 5 years.
NOTE: be aware all SOAP notes will be pass through Turnitin for plagiarism and AI use by school system.
Soap Note # and Diagnosis
Student Name:
Miami Regional University
Course Number:
Date of Encounter:
Preceptor Name/Clinical Site:
Faculty Instructor Name:
SOAP Note # and Diagnosis
PATIENT INFORMATION
Name: John Doe / Jane Doe
Age:
Gender at Birth:
Gender Identity:
Source: Patient or family member
SUBJECTIVE DATA
Chief Complaint: “A chief complaint is a concise statement ( in the patient’s
own words)” and the reason for seeking medical attention.
HPI: The History of Present Illness (HPI) involves a comprehensive discussion
driven by the patient's chief complaint or presenting symptom.
Review of Systems (ROS): ROS is an inventory of body systems obtained
through a series of questions seeking to identify signs and/or symptoms that the patient may
be experiencing or has experienced . Remember that in the ROS you should include both
negative and positive symptoms. They should help you define attributes and better understand
the problem.
ROS:
-Constitutional
-Eyes, Ears, Nose, Mouth / Throat
– Cardiovascular
-Respiratory
-Gastrointestinal
– Genitourinary
-Musculoskeletal
-Integumentary (skin, nail and hair)
– Hematologic/Lymphatic
-Endocrine
-Immunologic/ Allergic
-Neurological
-Psychiatric
Allergies (reaction):
Current Medications: List name, dose and frequency
Past Medical History:
Immunizations:
Preventive Care:
Last wellness exam:
Surgical History:
Family History:
Social History:
Sexual Orientation:
Nutrition History:
OBJECTIVE DATA
Vital Signs: Weight, height, BMI, BP, HR, RR, Temperature, and pain:
Physical Examination: is the process of evaluating objectively the body areas or
organ systems. The physical exam is documented either by the organ system or body areas.
Body areas recognized are the Head and Face, Neck, Chest (including breast and axillae),
Back (including spine), Abdomen, Genitalia, Groin, Buttocks, and each extremity (separately).
By organ system: General appearance, eyes, ENT and mouth, Cardiovascular,
Respiratory, GI, GU, Musculoskeletal, Endocrine, Skin, Neurologic, Psychiatric, and
hematology-Lymphatic -immunologic.
ASSESSMENT
The assessment section is where you summarize and analyze the information
collected to formulate your diagnosis.
Main Diagnosis (ICD-10 code): Use the literature to support your diagnosis and
include reference with (in-text citation).
Differential diagnoses condition (ICD-10 code): condition (ICD-10 code): A
differential diagnosis is a list of possible conditions that share the same symptoms. This list is
not the final diagnosis, but a theory as to what is potentially causing the symptoms. Possible
conditions will undergo a diagnostic process through different tests to eliminate those less
likely from your differential list and to identify the correct diagnosis.
PLAN
A plan refers to a detailed scheme for doing, arranging, or achieving something. It should
align with the diagnosis and potential underlying causes. The plan should include
non-pharmacologic and pharmacologic treatments, teaching, monitoring, follow-up, and
referral when applicable.
References
Example: Last name, first initial. (year). Title. Publisher. ***Hanging indent
is required for reference page. APA format will be used to submit your
assignments. For additional information on APA style formatting, please consult
the APA Style Manual, 7th Edition.
The MRU library and resource center provide valuable services, such as assistance
with APA style formatting to support students in their academic work.
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