FU SOAP Note Seeking Health Care Template

I’m working on a nursing case study and need a sample draft to help me study.

SOAP Note Template

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complete physical examination that will be performed on a person that is at 18-year-old or older

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Encounter date:________________________

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Patient Initials: ______ Gender: M/F/Transgender ____ Age:_____ Race: _____ Ethnicity ____

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Reason for Seeking Health Care: ______________________________________________

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HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________

Current perception of Health: ExcellentGoodFairPoor

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Past Medical History

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• Major/Chronic Illnesses____________________________________________________
• Trauma/Injury ___________________________________________________________
• Hospitalizations __________________________________________________________

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Past Surgical History___________________________________________________________

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Medications: __________________________________________________________________

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______________________________________________________________________________

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______________________________________________________________________________

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Family History: ____________________________________________________________

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Social history:

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Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________Employment Status: ______ Current/Previous occupation type: _________________

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Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________

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Sexual orientation: _______ Sexual Activity: ____ Contraception Use: ____________

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Family Composition: Family/Mother/Father/Alone: _____________________________

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Health Maintenance

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Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____

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Exposures:

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Immunization HX:

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Review of Systems:

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General:

HEENT:

Neck:

Lungs:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Activity & Exercise:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

Physical Exam

BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____

General:

HEENT:

Neck:

Pulmonary:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Derm:

Psychosocial:

Misc.

Plan:

Differential Diagnoses

1.

2.

3.

Principal Diagnoses

1.

2.

Plan

Diagnosis

Diagnostic Testing:

Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

Diagnosis

Diagnostic Testing:

Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

Signature (with appropriate credentials): __________________________________________

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________

DEA#:101010101 ClinicLIC# 10000000

Tel: (000) 555-1234FAX: (000) 555-12222

Patient Name: (Initials)______________________________Age ___________

Date: _______________

RX ______________________________________

SIG:

Dispense:___________Refill: _________________

No Substitution

Signature: ____________________________________________________________