Create a patient with diagnosis of Type 1 DM debut. S: O: A: P:SOAP note Template (Student Name)Mia
Create a patient with diagnosis of Type 1 DM debut. S: O: A: P:SOAP note Template (Student Name)Miami Regional UniversityDate of Encounter:Preceptor/Clinical Site:Clinical Instructor: ….. Soap Note # ____ Main Diagnosis ______________ PATIENT INFORMATIONName:Age:Gender at Birth: Gender Identity: Source:Allergies:Current Medications: PMH:Immunizations: Preventive Care: Surgical History: Family History:Social History: Sexual Orientation: Nutrition History: Subjective Data:Chief Complaint:Symptom analysis/HPI:The patient is … Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. ) CONSTITUTIONAL:NEUROLOGIC:HEENT: RESPIRATORY:CARDIOVASCULAR:GASTROINTESTINAL:GENITOURINARY: MUSCULOSKELETAL:SKIN: Objective Data:VITAL SIGNS: GENERAL APPREARANCE: NEUROLOGIC:HEENT: CARDIOVASCULAR: RESPIRATORY: GASTROINTESTINAL: MUSKULOSKELETAL:INTEGUMENTARY: ASSESSMENT:(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data) Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.) Main Diagnosis(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition. Differential diagnosis (minimum 3) Health Science Science Nursing MSN 5600L Share QuestionEmailCopy link Comments (0)
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