Unit 4 Assignment SOAP NOTE/Case Study 2 SOAP Note Patient Name: G.D. MRN: XXX Date of Service: 01-27-2020 Start Time: 10:00 AM End Time: 10:54 AM Billing Code(s): 90213, 90836 Accompanied by: Brother CC: Follow-up appointment for counseling after discharge from inpatient psychiatric unit 2 days ago Subjective (S): Mr. Davis reports generally improved depressive […]
Case Study: Emily Johnson is a 42-year-old female presenting for her annual wellness check-up. She has been experiencing occasional headaches and fatigue for the past three months. Emily works as a high school teacher and has noticed increased stress levels lately. She has a family history of hypertension and breast cancer. Emily is concerned about […]
SOAP Note Template Encounter date: ________________________ Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____ Reason for Seeking Health Care: ______________________________________________ HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________ Current perception of Health: Excellent Good Fair Poor Past Medical History • Major/Chronic Illnesses____________________________________________________ • Trauma/Injury ___________________________________________________________ • Hospitalizations __________________________________________________________ Past Surgical History___________________________________________________________ Medications: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Family […]
Psychiatric Case Study SOAP note Suicidal Ideation and Depression in Adolescent The patient is a 15‐year‐old Puerto Rican adolescent female living with both her parents and a younger sibling. Her parents presented with significant marital problems, had been separated several times and were discussing divorce. Her mother reported having a history of psychiatric treatment for […]
IT IS A SOAP NOTE, PROFESSOR ONLY ACCEPTED CLASS RESOURCES. Sufferers are continuously uncomfortable discussing with well being care skilled’s points that contain the genitalia and rectum; nonetheless, gathering an sufficient historical past and correctly conducting a bodily examination are very important. Analyzing case research of genital and rectal abnormalities may also help put together […]
Title: Documentation of downside primarily based evaluation of the neurological system. Objective of Project: Studying the required parts of documenting an issue primarily based subjective and goal evaluation of neurological system. Determine irregular findings. Course Competency: Apply evaluation methods for the neurological and respiratory techniques. Directions: Content material: Use of three sections: o Subjective o […]
Wk7 SOAP NOTE The shopper is 24 years outdated with a historical past of Bipolar, got here in for her routine go to. She reviews racing ideas, elevated emotionality, and issue staying on process. She reviews sleep is sweet and good appetites. The shopper is at the moment on Lithium 900 mg each day, Abilify […]
Operating head: SOAP NOTE 1 SOAP NOTE four Title: R.T Date: 03-16-2020 Age: 29 Intercourse: F SUBJECTIVE CC: “I’m urinating on a regular basis, and it burns after I urinate” HPI: It is a 29-year-old African American girl presenting immediately to the clinic with persevering with complaints of dysuria, urgency to urinate, and frequency of […]
Title: Documentation of the entire head to toe bodily evaluation. Goal of Task: To display the power to doc the findings of an goal head to toe evaluation and establish irregular findings. Course Competency: Show bodily examination abilities of the pores and skin, hair, nails, and musculoskeletal system. Prioritize applicable evaluation strategies for the gastrointestinal, […]
NSG6320 Grownup Well being – Adults & GerontologyWeek 9 SOAP NOTE Every week, you’re required to enter your affected person encounters into the SU medical monitoring system. Your school might be checking to make sure you are seeing the precise quantity and mixture of sufferers for studying expertise. Additionally, you will want to incorporate a […]
