Week 4 SOAP NOTE

Create a SOAP NOTE using the guidelines and template provided bellow.Topic: I have a painless lump on my left breast.CC: 40 y/o female. I noticed the lump 3 months ago. I was waiting for the lump to go away but it did not.Guidelines:Subjective Information: “CC”, HPI :OPQRST IF f/u: health status since last visit, response to therapies. PMH, PSH, FH, ROS complete.Objective Information: Complete physical exam with critical elements related to subjective data.Assessment: Minimum of 3 differentials supported by S + O data Final diagnosis noted, and optimal and thorough subjective and objective assessment is presented for final diagnosis.Plan: Diagnostic tests/therapies/follow-up, Patient education, health promotion. Medications listed with dosage/SE/Education/Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence-based reasoning & literature in designing plan of care, compare to plan of care implemented.

 

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