SOAP note about a geriatic patient.
SOAPNoteTemplate.docx SOAPNoteRubric1.pdf 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])