Executive Solution Overview
I need your expertise – ## GraduateSOAPNOTETEMPLATE.docx – ## advchealthwk7assign2.docx **## GraduateSOAPNOTETEMPLATE.docx**  **SOAP Note Template** Encounter date: ________________________ Patient Ini…
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– ## GraduateSOAPNOTETEMPLATE.docx
– ## advchealthwk7assign2.docx
**## GraduateSOAPNOTETEMPLATE.docx**
**SOAP Note Template**
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
**HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
**Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________
**Current perception of Health**: Excellent Good Fair Poor
**Past Medical History**
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
**Past Surgical History**\_\_\_________________________________________________________
**Medications:** __________________________________________________________________
\_\_\____________________________________________________________________________
\_\_\____________________________________________________________________________
**Family History:** ____________________________________________________________
**Social history**:
**Lives**: Single family House/Condo/ with stairs: ___________
**Marital Status**:________
**Employment Status**: ______
**Current/Previous occupation type**: _________________
**Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________
**Sexual orientation:** _______ Sexual Activity: ____
**Contraception Use**: ____________
**Family Composition:** Family/Mother/Father/Alone
**: _____________________________**
**Health Maintenance**
**Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____**
**Exposures:**
**Immunization HX:**
**Review of Systems:**
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
**Physical Exam**
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
**percentile**) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
****Significant Data/Contributing Dx/Labs/Misc.****
****Plan:****
****Differential Diagnoses****
****1.****
****2.****
****3.****
****Principal Diagnoses****
****1.****
****2.****
****Plan****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Signature (with appropriate credentials): __________________________________________****
****Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________****
****DEA#: 101010101 STU Clinic LIC# 10000000****
****Tel: (000) 555-1234 FAX: (000) 555-12222****
**Patient Name: (Initials)______________________________ Age ___________**
**Date: _______________**
****RX ______________________________________****
****SIG:****
****Dispense**: ___________**
****Refill:** _________________**
****No Substitution****
****Signature:** ____________________________________________________________**
****Copyright © MVJ 2018****
****image1.png****
**## advchealthwk7assign2.docx**
1. complete physical examination that will be performed on a person that is 18 years old or older.
2. Submit a typed SOAP Note of the 18years old physical assessment. Make sure to follow the proper sequential order in your physical assessment and use the correct terminology in your SOAP Note.
**SOAP Note Template**
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
**HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
**Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________
**Current perception of Health**: Excellent Good Fair Poor
**Past Medical History**
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
**Past Surgical History**\_\_\_________________________________________________________
**Medications:** __________________________________________________________________
\_\_\____________________________________________________________________________
\_\_\____________________________________________________________________________
**Family History:** ____________________________________________________________
**Social history**:
**Lives**: Single family House/Condo/ with stairs: ___________
**Marital Status**:________
**Employment Status**: ______
**Current/Previous occupation type**: _________________
**Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________
**Sexual orientation:** _______ Sexual Activity: ____
**Contraception Use**: ____________
**Family Composition:** Family/Mother/Father/Alone
**: _____________________________**
**Health Maintenance**
**Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____**
**Exposures:**
**Immunization HX:**
**Review of Systems:**
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
**Physical Exam**
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
**percentile**) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
****Significant Data/Contributing Dx/Labs/Misc.****
****Plan:****
****Differential Diagnoses****
****1.****
****2.****
****3.****
****Principal Diagnoses****
****1.****
****2.****
****Plan****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Signature (with appropriate credentials): __________________________________________****
****Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________****
****DEA#: 101010101 STU Clinic LIC# 10000000****
****Tel: (000) 555-1234 FAX: (000) 555-12222****
**Patient Name: (Initials)______________________________ Age ___________**
**Date: _______________**
****RX ______________________________________****
****SIG:****
****Dispense**: ___________**
****Refill:** _________________**
****No Substitution****
****Signature:** ____________________________________________________________**
**## advchealthwk7assign2.docx**
1. complete physical examination that will be performed on a person that is 18 years old or older.
2. Submit a typed SOAP Note of the 18years old physical assessment. Make sure to follow the proper sequential order in your physical assessment and use the correct terminology in your SOAP Note.
**SOAP Note Template**
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
**HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
**Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________
**Current perception of Health**: Excellent Good Fair Poor
**Past Medical History**
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
**Past Surgical History**\_\_\_________________________________________________________
**Medications:** __________________________________________________________________
\_\_\____________________________________________________________________________
\_\_\____________________________________________________________________________
**Family History:** ____________________________________________________________
**Social history**:
**Lives**: Single family House/Condo/ with stairs: ___________
**Marital Status**:________
**Employment Status**: ______
**Current/Previous occupation type**: _________________
**Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________
**Sexual orientation:** _______ Sexual Activity: ____
**Contraception Use**: ____________
**Family Composition:** Family/Mother/Father/Alone
**: _____________________________**
**Health Maintenance**
**Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____**
**Exposures:**
**Immunization HX:**
**Review of Systems:**
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
**Physical Exam**
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
**percentile**) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
****Significant Data/Contributing Dx/Labs/Misc.****
****Plan:****
****Differential Diagnoses****
****1.****
****2.****
****3.****
****Principal Diagnoses****
****1.****
****2.****
****Plan****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Signature (with appropriate credentials): __________________________________________****
****Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________****
****DEA#: 101010101 STU Clinic LIC# 10000000****
****Tel: (000) 555-1234 FAX: (000) 555-12222****
**Patient Name: (Initials)______________________________ Age ___________**
**Date: _______________**
****RX ______________________________________****
****SIG:****
****Dispense**: ___________**
****Refill:** _________________**
****No Substitution****
****Signature:** ____________________________________________________________**
**## GraduateSOAPNOTETEMPLATE.docx**
**SOAP Note Template**
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
**HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
**Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________
**Current perception of Health**: Excellent Good Fair Poor
**Past Medical History**
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
**Past Surgical History**\_\_\_________________________________________________________
**Medications:** __________________________________________________________________
\_\_\____________________________________________________________________________
\_\_\____________________________________________________________________________
**Family History:** ____________________________________________________________
**Social history**:
**Lives**: Single family House/Condo/ with stairs: ___________
**Marital Status**:________
**Employment Status**: ______
**Current/Previous occupation type**: _________________
**Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________
**Sexual orientation:** _______ Sexual Activity: ____
**Contraception Use**: ____________
**Family Composition:** Family/Mother/Father/Alone
**: _____________________________**
**Health Maintenance**
**Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____**
**Exposures:**
**Immunization HX:**
**Review of Systems:**
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
**Physical Exam**
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
**percentile**) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
****Significant Data/Contributing Dx/Labs/Misc.****
****Plan:****
****Differential Diagnoses****
****1.****
****2.****
****3.****
****Principal Diagnoses****
****1.****
****2.****
****Plan****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Signature (with appropriate credentials): __________________________________________****
****Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________****
****DEA#: 101010101 STU Clinic LIC# 10000000****
****Tel: (000) 555-1234 FAX: (000) 555-12222****
**Patient Name: (Initials)______________________________ Age ___________**
**Date: _______________**
****RX ______________________________________****
****SIG:****
****Dispense**: ___________**
****Refill:** _________________**
****No Substitution****
****Signature:** ____________________________________________________________**
****Copyright © MVJ 2018****
****image1.png****
**## advchealthwk7assign2.docx**
1. complete physical examination that will be performed on a person that is 18 years old or older.
2. Submit a typed SOAP Note of the 18years old physical assessment. Make sure to follow the proper sequential order in your physical assessment and use the correct terminology in your SOAP Note.
**SOAP Note Template**
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
**HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
**Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________
**Current perception of Health**: Excellent Good Fair Poor
**Past Medical History**
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
**Past Surgical History**\_\_\_________________________________________________________
**Medications:** __________________________________________________________________
\_\_\____________________________________________________________________________
\_\_\____________________________________________________________________________
**Family History:** ____________________________________________________________
**Social history**:
**Lives**: Single family House/Condo/ with stairs: ___________
**Marital Status**:________
**Employment Status**: ______
**Current/Previous occupation type**: _________________
**Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________
**Sexual orientation:** _______ Sexual Activity: ____
**Contraception Use**: ____________
**Family Composition:** Family/Mother/Father/Alone
**: _____________________________**
**Health Maintenance**
**Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____**
**Exposures:**
**Immunization HX:**
**Review of Systems:**
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
**Physical Exam**
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
**percentile**) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
****Significant Data/Contributing Dx/Labs/Misc.****
****Plan:****
****Differential Diagnoses****
****1.****
****2.****
****3.****
****Principal Diagnoses****
****1.****
****2.****
****Plan****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Signature (with appropriate credentials): __________________________________________****
****Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________****
****DEA#: 101010101 STU Clinic LIC# 10000000****
****Tel: (000) 555-1234 FAX: (000) 555-12222****
**Patient Name: (Initials)______________________________ Age ___________**
**Date: _______________**
****RX ______________________________________****
****SIG:****
****Dispense**: ___________**
****Refill:** _________________**
****No Substitution****
****Signature:** ____________________________________________________________**
**## GraduateSOAPNOTETEMPLATE.docx**
**SOAP Note Template**
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
**HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
**Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________
**Current perception of Health**: Excellent Good Fair Poor
**Past Medical History**
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
**Past Surgical History**\_\_\_________________________________________________________
**Medications:** __________________________________________________________________
\_\_\____________________________________________________________________________
\_\_\____________________________________________________________________________
**Family History:** ____________________________________________________________
**Social history**:
**Lives**: Single family House/Condo/ with stairs: ___________
**Marital Status**:________
**Employment Status**: ______
**Current/Previous occupation type**: _________________
**Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________
**Sexual orientation:** _______ Sexual Activity: ____
**Contraception Use**: ____________
**Family Composition:** Family/Mother/Father/Alone
**: _____________________________**
**Health Maintenance**
**Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____**
**Exposures:**
**Immunization HX:**
**Review of Systems:**
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
**Physical Exam**
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
**percentile**) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
****Significant Data/Contributing Dx/Labs/Misc.****
****Plan:****
****Differential Diagnoses****
****1.****
****2.****
****3.****
****Principal Diagnoses****
****1.****
****2.****
****Plan****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Signature (with appropriate credentials): __________________________________________****
****Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________****
****DEA#: 101010101 STU Clinic LIC# 10000000****
****Tel: (000) 555-1234 FAX: (000) 555-12222****
**Patient Name: (Initials)______________________________ Age ___________**
**Date: _______________**
****RX ______________________________________****
****SIG:****
****Dispense**: ___________**
****Refill:** _________________**
****No Substitution****
****Signature:** ____________________________________________________________**
****Copyright © MVJ 2018****
****image1.png****
**## advchealthwk7assign2.docx**
1. complete physical examination that will be performed on a person that is 18 years old or older.
2. Submit a typed SOAP Note of the 18years old physical assessment. Make sure to follow the proper sequential order in your physical assessment and use the correct terminology in your SOAP Note.
**SOAP Note Template**
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
**HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
**Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________
**Current perception of Health**: Excellent Good Fair Poor
**Past Medical History**
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
**Past Surgical History**\_\_\_________________________________________________________
**Medications:** __________________________________________________________________
\_\_\____________________________________________________________________________
\_\_\____________________________________________________________________________
**Family History:** ____________________________________________________________
**Social history**:
**Lives**: Single family House/Condo/ with stairs: ___________
**Marital Status**:________
**Employment Status**: ______
**Current/Previous occupation type**: _________________
**Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________
**Sexual orientation:** _______ Sexual Activity: ____
**Contraception Use**: ____________
**Family Composition:** Family/Mother/Father/Alone
**: _____________________________**
**Health Maintenance**
**Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____**
**Exposures:**
**Immunization HX:**
**Review of Systems:**
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
**Physical Exam**
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
**percentile**) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
****Significant Data/Contributing Dx/Labs/Misc.****
****Plan:****
****Differential Diagnoses****
****1.****
****2.****
****3.****
****Principal Diagnoses****
****1.****
****2.****
****Plan****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Diagnosis****
****Diagnostic Testing:****
****Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Signature (with appropriate credentials): __________________________________________****
****Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________****
****DEA#: 101010101 STU Clinic LIC# 10000000****
****Tel: (000) 555-1234 FAX: (000) 555-12222****
**Patient Name: (Initials)______________________________ Age ___________**
**Date: _______________**
****RX ______________________________________****
****SIG:****
****Dispense**: ___________**
****Refill:** _________________**
****No Substitution****
****Signature:** ____________________________________________________________**
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