SOAP NOTE: Abdominal PainSOAP NOTE TEMPLATE Review the Rubric for more Guidance |
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| 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 |
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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])