Soap Note Diabetes Mellitus

 1) Identifying Data : The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given 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. 2) Subjective Data : This is the historical part of the note. It contains the following: a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations. b) Review of systems of associated systems, reporting all pertinent positives and negatives . c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem . If more than one chief complaint, each should be written u in this manner. 3) Objective Data : Vital signs need to be present. Height and Weight should be included where appropriate. a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b. b) Pertinent positives and negatives must be documented for each relevant system. c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. 4) Assessment : Diagnoses should be clearly listed and worded appropriately. 5) Plan : Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections. 6) Subjective/ Objective, Assessment and Management and Consistent : Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified. Must be an APA format.

#Soap #Note #Diabetes #Mellitus

Table of Contents

Calculate your order
Pages (275 words)
Standard price: $0.00

Latest Reviews

Impressed with the sample above? Wait there is more

Related Questions

Opportunity cost

 All essays must be typed in size 12 Times New Roman font, double-spaced, and with one-inch margins. Be sure to include an introduction and conclusion.

INTRO TO ANIMAL SCIENCES

Health management and disease control is important in any industry. This is especially true when raising poultry and swine. What types of biosecurity protocols might

New questions

Don't Let Questions or Concerns Hold You Back - Make a Free Inquiry Now!