Focused SOAP Note and Patient Case Presentation

Focused SOAP Note and Patient Case Presentation
For this Assignment, you will document information about a patient that you examined, using the Focused SOAP Note Template provided. Create a Focused SOAP Note on this patient using the template provided in the attachment. (There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.)

Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning. Your five scholarly sources must be within 5 years.

Subjective:

CC (chief complaint):

HPI:

Substance Current Use:

Medical History:

·       Current Medications:

·       Allergies:

• Reproductive Hx:

ROS:

·       GENERAL:

·       HEENT:

·       SKIN:

·       CARDIOVASCULAR:

·       RESPIRATORY:

·       GASTROINTESTINAL:

·       GENITOURINARY:

·       NEUROLOGICAL:

·       MUSCULOSKELETAL:

·       HEMATOLOGIC:

·       LYMPHATICS:

·       ENDOCRINOLOGIC:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Diagnostic Impression:

Reflections:

Case Formulation and Treatment Plan: 

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