HYPERTENSION DIAGNOSIS
Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.
You must use the template provided ATTACHED. Turnitin will recognize the template and not score against it.
Complete and submit the assignment using the appropriate template in MS Word
| SOAP NOTE TEMPLATE
Review the Rubric for more Guidance |
|
| Demographics | |
| Chief Complaint (Reason for seeking health care) | |
| History of Present Illness (HPI) | |
| Allergies | |
| Review of Systems (ROS) | General:
HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: Nutrition: Sleep/Rest: LMP: STI Hx: |
| Vital Signs | |
| Labs | |
| Medications | |
| Past Medical History | |
| Past Surgical History | |
| Family History | |
| Social History | |
| Health Maintenance/ Screenings | |
| Physical Examination | General:
HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: |
| Diagnosis | |
| Differential Diagnosis | |
| ICD 10 Coding | |
| Pharmacologic treatment plan | |
| Diagnostic/Lab Testing | |
| Education | |
| Anticipatory Guidance | |
| Follow up plan | |
| Prescription | See Below (scroll down) |
| References | |
| Grammar |
| EA#: 101010101 STU Clinic LIC# 10000000 |
| Tel: (000) 555-1234 FAX: (000) 555-12222 |
|
Patient Name: (Initials)______________________________ Age ___________ Date: _______________ RX ______________________________________ SIG: Dispense: ___________ Refill: _________________ No Substitution
Signature:____________________________________________________________ |
Signature (with appropriate credentials):_____________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])