Write a SOAP note about a patient who is suffering from colon cancer
Write a SOAP note about a patient who is suffering from colon cancer and use the following acronym:
Use the attached template and follow the attached rubrics carefully. I will submit the assignment to Turnitin before submission. Similarity should be under 20%.
| S = | Subjective data: Patient’s Chief Complaint (CC). |
| O = | Objective data: Including client behavior, physical assessment, vital signs, and meds. |
| A = | Assessment: Diagnosis of the patient’s condition. Include differential diagnosis. |
| P = | Plan: Treatment, diagnostic testing, and follow up |
Encounter date: ________________________
Patient Initials: ______Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________
Current perception of Health: Excellent Good Fair Poor
Past Medical History
- Major/Chronic Illnesses____________________________________________________
- Trauma/Injury ___________________________________________________________
- Hospitalizations __________________________________________________________
Past Surgical History___________________________________________________________
Medications: __________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Family History: ____________________________________________________________
Social history:
Lives: Single family House/Condo/ with stairs: ___________Marital Status:________Employment Status: ______Current/Previous occupation type: _________________
Exposure to: ___Smoke____ ETOH____Recreational Drug Use: __________________
Sexual orientation: _______ Sexual Activity: ____Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone: _____________________________
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____
Exposures:
Immunization HX:
Review of Systems:
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 STUClinicLIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)______________________________ Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________ Refill: _________________
No Substitution
Signature: ____________________________________________________________
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