Posted: February 15th, 2022

Soap Note Unspecified Conjuntivitis

(Scholar Title)

Miami Regional College

Date of Encounter:

Preceptor/Scientific Website:

Scientific Teacher: Patricio Bidart MSN, APRN, FNP-C

Soap Note # ____ Essential Analysis ______________

PATIENT INFORMATION

Title:

Age:

Gender at Start:

Gender Id:

Supply:

Allergy symptoms:

Present Drugs:

·

PMH:

Immunizations:

Preventive Care:

Surgical Historical past:

Household Historical past:

Social Historical past:

Sexual Orientation:

Diet Historical past:

Subjective Information:

Chief Grievance:

Symptom Assessment/HPI:

The affected person is …

Assessment of Programs (ROS) (This part is what the affected person says, subsequently ought to state Pt denies, or Pt states….. )

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL:

SKIN:

Goal Information:

VITAL SIGNS:

GENERAL APPREARANCE:

NEUROLOGIC:

HEENT:

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:

ASSESSMENT:

(In a paragraph please state “your encounter together with your affected person and your findings ( together with subjective and goal knowledge)

Instance : “Pt got here in to our clinic c/o of ear ache. Pt states that the ache began three days in the past after swimming. Pt denies discharge and so forth… on examination I famous this and that and so forth.)

Essential Analysis

(Embody the identify of your Essential Analysis together with its ICD10 I10. (Have a look at PDF instance offered) Embody the in-text reference/s as per APA fashion sixth or seventh Version.

Differential prognosis (minimal three)

–

–

–

PLAN:

Labs and Diagnostic Take a look at to be ordered (if relevant)

· –

· –

Pharmacological remedy:

–

Non-Pharmacologic remedy:

Training (present probably the most related ones tailor-made to your affected person)

Comply with-ups/Referrals

References (in APA Type)

Examples

Codina Leik, M. T. (2014). Household Nurse Practitioner Certification Intensive Assessment (2nd ed.).

ISBN 978-Zero-8261-3424-Zero

Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Scientific Seek the advice of 2010

(25th ed.). Print (The 5-Minute Seek the advice of Sequence).

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