Each Week You Are Required To Enter Your Patient Encounters Into Core Your Faculty W 2838714

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning inWeek 5, you will need to include one complete SOAP note each week throughWeek 9 for a total of 5 complete SOAP notes for this course using thisSOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to theSubmissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry. Document Preview:

SOAP NOTE Name: Date: Time: Age: Sex: SUBJECTIVE CC: Reason given by the patient for seeking medical care “in quotes” HPI: Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness. Medications: (list with reason for med ) PMH Allergies: Medication Intolerances: Chronic Illnesses/Major traumas Hospitalizations/Surgeries “Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.” Family History Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease. Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse,ETOH, tobacco, marijuana. Safety status ROS General Cardiovascular Weight change, fatigue, fever, chills, night sweats, Chest pain, palpitations, PND, orthopnea, edema energy level Skin Respiratory Delayed healing, rashes, bruising, bleeding or skin Cough, wheezing, hemoptysis, dyspnea, pneumonia discolorations, any changes in lesions or moles hx, TB Eyes Gastrointestinal Corrective lenses, blurring, visual changes of any Abdominal pain, N/V/D, constipation, hepatitis, kind hemorrhoids, eating disorders, ulcers, black tarry stools Ears Genitourinary/Gynecological Ear pain, hearing loss, ringing in ears, discharge Urgency, frequency burning, change in color of urine. Contraception, sexual activity, STDS Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx Male: prostate, PSA,…

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SOAP-Blank-Te….pdf

Prof. Angela

4.6/5

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