I have a painless lump on my left breast.
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Create a SOAP NOTE using the guidelines and template provided bellow.
Topic: I have a painless lump on my left breast.
CC: 40 y/o female. I noticed the lump 3 months ago. I was waiting for the lump to go away but it did not.
Guidelines:
Subjective Information: CC, HPI :OPQRST IF f/u: health status since last visit, response to therapies. PMH, PSH, FH, ROS complete.
Objective Information: Complete physical exam with critical elements related to subjective data.
Assessment: Minimum of 3 differentials supported by S + O data Final diagnosis noted, and optimal and thorough subjective and objective assessment is presented for final diagnosis.
Plan: Diagnostic tests/therapies/follow-up, Patient education, health promotion. Medications listed with dosage/SE/Education/
Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence-based reasoning & literature in designing plan of care, compare to plan of care implemented.
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