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Learning Goal: I’m working on a nursing report and need a sample publish to help m

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Learning Goal: I’m working on a nursing report and need a sample publish to help me learn.
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: ExcellentGoodFairPoor
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.

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:

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