SOAP Template for Tina Jones Comprehensive Assessment

 (SOAP Template for Comprehensive SOAP Note)

Age:

Gender/Race/Culture:

Historian Type:

Historian

·        CREATE a Current Patient Problem List

·        update this as you find problems in the History & Physical

·        (Active or Resolved)               

o   Example:  [HTN-Active or Asthma-Active]

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Chief Complaint in Patient’s own Words (use quotations)  1 pt

(What do you think your working diagnoses are after the subjective portion) 2 pt

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Medications  

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Type/Purpose of Exam: 

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M,F, S, B, PGM, etc. Disease/age/(Alive/Deceased)

Occupation, resources, cultural practices, home living conditions, sexual practices Marital status, Tobacco Use/ ETOH/Illicit Drug Use, Sexual activity/Birth Control, Hobbies. SOAP Template for Tina Jones Comprehensive Assessment

REVIEW OF SYSTEMS

OBJECTIVE DATA

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Constitutional/General:   

 Lab and Diagnostics tests completed during the exam to guide you to the diagnosis.  State the lab or procedure done and the specific results of your findings   (A diagnostic may be a blood sugar obtained during the visit). SOAP Template for Tina Jones Comprehensive Assessment

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ASSESSMENT/IMPRESSION   3 pts                                 DIFFERENTIAL DX:   (Scored Below) 3 pt

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6. Include risk Profile for….

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 Be specific.   Include all 6 components of Plan.     Each diagnosis must be addressed in Plan

Therapeutics:

Pharmacotherapeutics:

Patient Education:

HPDP/Safety Discussions (Smoking, occupational exposure, FH CAD, Safety- Car seats, gun safety etc)

Referral:

Follow Up:

Diagnoses #2:  ___________________

Therapeutics:

Pharmacotherapeutics:

Patient Education:

HPDP/Safety Discussions (Smoking, occupational exposure, FH CAD, Safety- Car seats, gun safety etc)

Referral:

Follow Up:

Diagnoses #3:  ___________________

Therapeutics:

Pharmacotherapeutics:

Patient Education:

HPDP/Safety Discussions (Smoking, occupational exposure, FH CAD, Safety- Car seats, gun safety etc) SOAP Template for Tina Jones Comprehensive Assessment

Referral:

Follow Up:

Diagnostic Reasoning/Differentials

Differentials EVIDENCED BASED SUPPORT  (APA Format Reference Styles)  8 pts   

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Briefly discuss the how you decided on the final diagnosis and list supporting evidence to support eliminating the other differentials in order to support your decision of Final Diagnosis (Cite your References and supporting data)

Include supporting data/Cite References)

Include supporting Data & References