IAN BORO

SAMPLE FOCUS NOTE CHIEF COMPLAINT (C/C) “I have trouble breathing” HISTORY OF PRESENT ILLNESS (HPI) 24-year-old single, domicile, Hispanic female presents to the Clinic with complain of difficulty breathing times 3 days. She reported her symptoms began with her having what she considered a common cold 3days,ago andworsened over the next 2 daysresulting in persistent […]

PEPTIC ULCER DISEASE DUE TO HELYCOBACTER PYLORI. Instructions This is a soap note for a patient coming in with symptoms of peptic ulcer caused by h-pylori Primary diagnosis– h.pylori peptic ulcer Differential diagnosis– GERD, IBS,cholecystitis, pancreatitis References no older than 2 years No cover page use attached document Solution   FOCUSED NOTE: PEPTIC ULCER DISEASE

Focused SOAP Note Template   Patient Information: Initials, Age, Sex, Race S. CC (chief complaint): A brief statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” not “bad headache for 3 days”). HPI: This is the symptom analysis section of your note. Thorough documentation in this section is

Musculoskeletal and Neurological Disorders Felipe is a 70-year-old Hispanic male who presents to the urgent care clinic accompanied by his wife and neighbor. According to the history, he had been on a ladder cleaning windows and then had fallen to the floor, called out and his wife, Lucinda, heard him and went to help him

Episodic/Focused SOAP Note Exemplar Focused SOAP Note for a patient with chest pain S. CC: “Chest pain” HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning.  The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The

Chronic illness SOAP note and clinical decision making using 2 EBP Instructions Select a patient that you have encountered in your clinical practice with a chronic health problem. Interview the client/family members. Include the following information- Setting: Community clinic, Private practice, Skilled nursing facility, Home health Clinical information: Chief complaint, HPI, PMH, PSH, FH, ROS,

Medial knee osteoarthritis SOAP Note Instructions Select a client from clinical experience with an acute health problem or complaint requiring at least two visits. Submit a complete H & P from the initial visit with this client and a focused SOAP note for the follow-up visit. Based on this client’s condition, conduct a literature search

Obstetric Case Study Assignment Pregnancy Jania, a 26-year-old single Hispanic woman presents for an appointment after a positive home pregnancy test. She states that this is a planned pregnancy. She is very sure that the first day of her last menstrual period was June 29th (assume today is August 22nd). She has experienced fatigue, daily