Patient Initials: Pt. Encounter Number: Date: Age: Sex: Allergies: Advanced Directives: SUBJECTIVE CC:
Patient Initials:
Pt. Encounter Number:
Date:
Age:
Sex:
Allergies: Advanced Directives:
SUBJECTIVE
CC:
HPI: Describe the course of the patient’s illness:
Onset:
Location:
Duration:
Characteristics:
Aggravating Factors:
Relieving Factors:
Treatment:
Current Medications:
PMH
Medication Intolerances:
Chronic Illnesses/Major traumas:
Screening Hx/Immunizations Hx:
Hospitalizations/Surgeries:
Family History:
Social History:
ROS
General
Cardiovascular
Skin
Respiratory
Eyes
Gastrointestinal
Ears
Genitourinary/Gynecological
SOAP NOTE
Nose/Mouth/Throat
Musculoskeletal
Breast
Neurological
Heme/Lymph/Endo
Psychiatric
OBJECTIVE
Weight BMI
Temp
BP
Height
Pulse
Resp
PHYSICAL EXAMINATION
General Appearance
Skin
HEENT
Cardiovascular
Respiratory
Gastrointestinal
Breast
Genitourinary
Musculoskeletal
Neurological
Psychiatric
Lab Tests
Special Tests
Diagnosis
· Primary Diagnosis-
Evidence for primary diagnosis should be documented in your Subjective and
Objective exams.
o Differential Diagnoses – Include three diagnoses
PLAN including education
o Plan:
Further testing
Medication
Education
Non-medication treatments
· Referrals
Follow-up visits
References
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
