For soap notes # 1, you will select any topic of your choice that was covered in your health assessment class, from week 1 to week 9 (from chapter 1 to chapter 20). Please note that you cannot select any system that has not been covered in lecture.
******The attached FNU soap note template is required for all soap note assignments.
******All Assignments are graded according to the attached rubric.
For assignment contents, please refer to the following:
Demographic information
Subjective:
Chief complaint
HPI (History of present illness)
Past Medical History (PMH)
Past Surgical History (PSH)
Currents Conditions: Allergies, Maintenance medications/OTCs, Immunizations.
Family History
Social History (work, relationship, lifestyle (diet, exercise, sleep, tobacco, smoking)
ROS (Review of Systems): Systematic, organized, and Thorough (What the patient or the caregiver reports)
Objective
Vital signs, Weight, Height, BMI, and any other relevant parameters
General survey
Physical examination is systematic, organized, thorough and related to the reason of the visit.
Main Diagnosis: Based on your subjective and objective findings. Must be supported.
List of 3 Differential Diagnosis: No more than 3. Each ddx must be supported and cited. 1 different citation for each (not the same author).
Plan of care/Intervention
Diagnostic tests/therapies/medications. Prescription must be complete: dosage, frequency, duration, special instructions in relation to food.
Follow-up/Pt. Education and Health Promotion -Very important.
Ensure that education about medications and their side effects are addressed.
Health promotion is a must.
References: References must be APA formatted.
