NEURO SOAP
- For this week’s documentation, though you will only record the neurological exam, you will be expected to write an entire SOAP note.
- Create a neuro-related CC. Create an ID, CC, HPI, ROS, V/S, physical findings, and assessment with at least 3 differential diagnoses, a final diagnosis, and treatment plan in a SOAP note format. Use a neuro related CC that a patient would present with in a primary care setting (i.e. no emergency room or ICU type complaints). Examples: regular headaches, migraines, dizziness, dementia or memory loss, weakness, neuropathy, etc..
- Include at least two references for your diagnostic and treatment plan. They should be recent (in the last 5-10 years) and peer-reviewed. Use APA title page, citation, and references. Ensure the treatment plan includes all components (diagnostic plan, therapeutic plan, education plan, and follow up).
- The ROS and physical exam in your document should be written up as they would be for a problem focused visit. The neurological part of the physical exam write up should be a comprehensive write up, including everything you assessed in your recording. The neuro portion of the SOAP note is usually a full page or page and a half when done well.
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