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Write a SOAP note from a patient who comes to the medical office with suppurativ

Write a SOAP note from a patient who comes to the medical office with suppurative otitis media. You can be guided by the guide lines and the added rubrics below.
Guidelines
for SOAP Notes
General Guidelines:
• Label each section of the SOAP note (each body part and
system).
• Do not use unnecessary words or complete sentences.
• Use Standard Abbreviations
• All Heading and Subheadings must be bolded and separate,
no narrative ROS or Physical
(Paragraph Form)
All Soap Notes must include:
• Full name of student
• Date of encounter
• Name of Preceptor and Clinical Instructor
• Title with Soap # and Main Diagnosis (Soap # 3 DX:
Hypertension)
S: SUBJECTIVE DATA (information the patient/caregiver tells
you).
Identifying Information: The opening list of the note. It
contains age, sex, race, marital status, etc. The
patient complaint should be given in quotes.
Chief Complaint (CC): a statement describing the patient’s
symptoms, problems, condition, diagnosis,
physician-recommended return(s) for this patient visit. The
patient’s own words should be in “quotes”.
. If the patient has more than one complaint, each complaint
should be listed separately (1, 2, etc.) and
each addressed in the subjective and under the appropriate
number.
History of present illness (HPI): a chronological
description of the development of the patient’s chief
complaint from the first symptom or from the previous
encounter to the present. Include the eight
variables (Onset, Location, Duration, Characteristics,
Aggravating Factors, Relieving Factors, Treatment,
Severity-OLDCARTS), or an update on health status since the
last patient encounter.
Past Medical History (PMH): Update current medications,
allergies, prior illnesses and injuries,
operations and hospitalizations allergies, age-appropriate
immunization status.
Family History (FH): Update significant medical information
about the patient’s family (parents, siblings,
and children). Include specific diseases related to problems
identified in CC, HPI or ROS.
Social History(SH): An age-appropriate review of significant
activities that may include information such
as marital status, living arrangements, occupation, history
of use of drugs, alcohol or tobacco, extent of
education and sexual history.
Review of Systems (ROS). There are 14 systems for review.
List positive findings and pertinent negatives
in systems directly related to the systems identified in the
CC and symptoms which have occurred since
last visit; (1) constitutional symptoms (e.g., fever, weight
loss), (2) eyes, (3) ears, nose, mouth and
throat, (4) cardiovascular, (5) respiratory, (6)
gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9}. integument (skin
and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13)
hematological/lymphatic, {14) allergic/immunologic. The ROS
should mirror the PE findings section.
All Sections must be included in all soap notes
0: OBJECTIVE DATA (information you observe, assessment
findings, lab results).
Sufficient physical exam should be performed to evaluate
areas suggested by the history and patient’s
progress since last visit. Document specific abnormal and
relevant negative findings. Abnormal or
unexpected findings should be described
Record observations for the following systems for each
patient encounter (there are 12 possible
systems for examination): Constitutional (e.g. vital signs,
general appearance), Eyes, ENT/mouth,
Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin,
Neurological, Psychiatric,
Hematological/lymphatic/immunologic/lab testing.
Testing Results: Results of any diagnostic or lab testing
ordered during that patient visit.
A: ASSESSMENT: (this is your diagnosis (es) with the
appropriate ICD 10 code)
List and number the possible diagnoses (problems) you have
identified. These diagnoses are the
conclusions you have drawn from the subjective and objective
data.
There must be one main Diagnosis
Remember: Your subjective and objective data should support
your diagnoses and therapeutic plan.
Do not write that a diagnosis is to be “ruled out”
rather state the working definitions of each differential
or primary diagnosis (es).
For the main diagnoses provide a cited rationale for
choosing this diagnosis. This rationale includes a
one sentence cited definition of the diagnosis (es) the
pathophysiology, the common signs and
symptoms, the patients presenting signs and symptoms and the
findings and tests results that support
the dx. Include the interpretation of all lab data given in
the case study and explain how those results
support your chosen diagnosis.
Must include a Minimum of 3 differential diagnosis with ICD
codes
P: PLAN (this is your treatment plan specific to this
patient). Each step of your plan must include an EBP
citation. (in-text citation)
1. Medications write out the prescription including
dispensing information and provide EBP to support
ordering each medication. Be sure to include both
prescription and OTC medications.
2. Additional diagnostic tests include EBP citations to
support ordering additional tests
3. Education this is part of the chart and should be brief,
this is not a patient education sheet and needs
to have a reference.
4. Referrals include citations to support a referral
5. Follow up. Patient follow-up should be specified with
time or circumstances of return. You must
provide a reference for your decision on when to follow up.
6. References: Notes must have Minimum of 2 Scholarly
References ( Journals, Books, and Studies)

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