- using the template attached make a soap note on a 56 year old afriacn american female with a diagnosis of Hypertension
- review the Comprehensive SOAP Note Template.
- Select a patient who you saw at your practicum site during the last 5 weeks. With this patient in mind, consider the following:
- Subjective: What details did the patient provide regarding the personal and medical history?
- Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
- Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What was your primary diagnosis and why?
- Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
- Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
COMPREHENSIVE SOAP NOTE on a 56 year old women with Hypertension, must use attached soap note format and follow rubric perfectly
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