Miami Dade College Mini SOAP Note Worksheet Nursing Assignment Help

Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit here as a Word Document. See the example template below for the required format.

Review the rubric for more information on how your assignment will be graded.


63 y/o male with BHP, presents to the clinic for 1 year follow up and refill medication.

Problem-Focused SOAP Note Format

Demographic Data

  • Age, and gender (must be HIPAA compliant)

Subjective

  • Chief Complaint (CC) unless an Annual Physical Exam (APE)
  • History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)
  • Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance as applicable
  • Family Hx: As applicable
  • Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
  • Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)

Objective

  • Vital signs
  • Physical findings listed by body systems, not paragraph form

Assessment (Diagnosis/ICD10 Code)

  • Include all diagnoses that apply for this visit

Plan

  • Dx Plan (lab, x-ray)
  • Tx Plan: (meds)
  • Pt. Education, including specific medication teaching points
  • Referral/Follow-up
  • Health maintenance (including when screenings, immunizations, etc., are next due):

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

Understanding how the health care system works and evolves Nursing Assignment Help

Understanding how the health care system works and evolves provides health care administrators and leadership with awareness of the position of their organization and facilitates compliance with health regulations. Discuss in detail each component of the U.S. delivery system, its function, and how it supports the delivery of care. Describe

Unit 3 focused on both the nervous and endocrine systems. Nursing Assignment Help

Unit 3 focused on both the nervous and endocrine systems. Both are essential communication systems for the body and play vital roles in homeostatic balance. The endocrine system produces chemical messengers that travel throughout the body via the circulatory system and interact with receptor cells. If the interaction cannot occur,

To Prepare Review the interactive media piece for Nursing Assignment Help

To Prepare  Review the interactive media piece for Alzheimer’s Disease.  (76 Year Old Iranian Male) Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece. Consider how you might assess and treat patients presenting with the symptoms of the patient case study you were assigned. You

Students are required to maintain weekly reflective Nursing Assignment Help

Students are required to maintain weekly reflective narratives throughout the course to combine into one course-long reflective journal that integrates leadership and inquiry into current practice as it applies to the Professional Capstone and Practicum course. In your journal, you will reflect on the personal knowledge and skills gained throughout

Students are required to maintain weekly reflective Nursing Assignment Help

Students are required to maintain weekly reflective narratives throughout the course to combine into one course-long reflective journal that integrates leadership and inquiry into current practice as it applies to the Professional Capstone and Practicum course. In your journal, you will reflect on the personal knowledge and skills gained throughout