Axia Material SOAP Note Create three SOAP notes using correct medical terminology from the patient information in Appendix C. * Organize the information correctly * Format the SOAP notes * Revise language where necessary Post your paper as a Microsoft® Word attachment. Patient One – Chapter 6 Soap Notes Date: | 09/26/2011 | Chart: | 001 | Age: | 22 | Name: | Jane Doe | Date of Birth: | 02/11/89 | Sex: | F | S: | Patient has sever lower back pain that
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SOAP Note Create three SOAP notes using correct medical terminology from the patient information in Appendix C. • Organize the information correctly • Format the SOAP notes • Revise language where necessary Post your paper as a Microsoft® Word attachment. Patient One – Chapter 6 Soap Notes Date: Sat‚ Aug 27‚ 2011 04:05 pm Chart #: 1234-567-1234 Age: 22 Name: Susan Smith Date of Birth: 03/11/89 Sex : F S: Patient says she has been having acute back discomfort over the
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J.L. SOAP NOTE Subjective J.L. is a 63-year-old white female who presented to the ER with right lower extremity pain and swelling with subsequent changes to the skin‚ including formation of bullous ulcers. She had blistering over the past four days that started to enlarge. The doctor prescribed her Bactrim. Erythema‚ swelling‚ and pain progressively got worse. She denies any fever or chills. PMH: COPD‚ Hypertension‚ Diabetes mellitus‚ Osteoporosis‚ Fibromyalgia‚ Osteoarthritis‚ Morbid obesity
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DATE AND TIME S: No events overnight. Pt. complains of… Pt denies HA‚ changes in vision‚ CP‚ Palpitations‚ SOB‚ Nausea‚ Vomiting‚ Diarrhea‚ Constipation‚ bowel movement and consistency. Tolerated PO meds well. Last bowel movement Meds: Antibiotics w: day # Labs: Also note which labs are pending and any significant changes or trends with arrows. Cl- BUN Na K+ HCO3 Cr WBC Hgb Hct PT Glu Plt Pulse: Resp: BP (w/ range): I/O:: O: Vitals: Tmax: Tcurr: Glucose
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SOAP Note—Hair‚ Skin‚ Nails Subjective: Mark W. comes to the clinic today with complaint of “I have an itchy red rash that I think is from Poison Oak.” Patient states that rash is on both legs from the knees down to feet; reports that it developed approx. 24 hours after a hiking trip last weekend. Denies pain. Denies nausea‚ vomiting‚ fever. Reports “itching‚ burning legs and feet.” Patient reports having had this reaction to Poison Oak twice before. No other allergies reported. Reports
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SM 420 Therapeutic Modalities Fall 2012 EXTRA CREDIT PROJECT This extra credit project is to replace your lowest exam score for the semester…. Not your final exam score. You are to compose a paper on a therapeutic modality. Ideally it should be one we have covered in class. Be sure to check with me about your specific topic ****If you wish to research an additional modality‚ please talk with me first. The paper is voluntary and there will be no points deducted from any exam. However is your
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ENGLISH 4U ACTIVE READING NOTES While you read your chosen novels and other relevant material you should be keeping notes. The goal is to jot down ideas and thoughts as you are reading‚ thus making the process active. You should write something every time you read. Your instinct may be to write your opinion of what you have read. While this is okay to include in reading notes‚ reserve these comments for your reading log. Your active reading notes should be of more substance in order to
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Patient Information | NAME: | Sharon Doe | Today’s DATE: | _11__ / 29_ / 2012_ | CLIENT: | * Established Client | * New Client | GENDER: | * Male | X Female | MEDICAL RECORD #: | | Hispanic‚ Latino‚ or Spanish Origin | X Non- Hispanic | * Hispanic: (origin: ) | RACE: | * American Indian or Alaska Native | * Asian | X Black/ African American | * Native Hawaiian / Other Pacific Islander | * White
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The SOAP note is the accepted method of medical record entries for the military. S: (subjective) - What the patient tells you. O: (objective) - Physical findings of the exam. A: (assessment) - Your interpretation of the patients condition. P: (plan) - Includes the following: 1. Medical treatment: includes use of meds‚ use of bandages‚ etc. 2. Additional diagnostics: which if any test which still might be needed. X-ray MRI ect.. 3. Special instructions‚ handouts‚ use
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SOAP NOTES The acronym SOAP defines four sections: (S) for subjective‚ (O) for objective‚ (A) for assessment‚ and (P) for plan. The SOAP note format is common to the medical setting and is used by many health care professionals. Subjective (S). The subjective section should include information given or statements made by the patient or the patient family in relation to the current deficits or ability to participate in evaluation or treatment sessions. For example‚ a patient who exhibits significant
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