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SOAP NOTE TEMPLATE Review the Rubric for more Guidance Demographics

September 24, 2024

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

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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])

>Nursing homework help

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