Select a patient that you examined during the last four weeks. With this patient in mind, address the following in a SOAP Note:
Subjective: What details did the patient provide regarding or her personal and medical history?
Objective: What observations did you make during the physical assessment?
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What would you do differently in a similar patient evaluation?
(THE TOPIC HERE IS URINARY TRACT INFECTION (UTI) )
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Comprehensive SOAP Template
Patient Initials: Age: Gender: F
Introduction –Purpose:
SUBJECTIVE DATA:
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies: Seafood, iodine
Past Medical History (PMH):
Past Surgical History (PSH): Denies.
Sexual/Reproductive History (Obstetric):
Personal/Social History:
Immunization History and Preventive Care:
Significant Family History:
.
Review of Systems:
General:
HEENT:
Respiratory:
Cardiovascular:
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