Create a SOAP NOTE using the guidelines and template provided bellow.
Topic: I have a discomfort on my abdomen and I’m always tired.
CC: 30 y/o female with multiple sexual partners without protection, flu-like symptoms, fatigue and mouth ulcers.
Guidelines:
Subjective Information: “CC”, HPI :OPQRST IF f/u: health status since last visit, response to therapies. PMH, PSH, FH, ROS complete.
Objective Information: Complete physical exam with critical elements related to subjective data.
Assessment: Minimum of 3 differentials supported by S + O data Final diagnosis noted, and optimal and thorough subjective and objective assessment is presented for final diagnosis.
Plan: Diagnostic tests/therapies/follow-up, Patient education, health promotion. Medications listed with dosage/SE/Education/
Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence-based reasoning & literature in designing plan of care, compare to plan of care implemented.
