SOAP Note 13-17 Wellness: FNP 592: Common Illnesses Across the Lifespan…
United States University
Student name
FNP 592: Common Illnesses Across the Lifespan
Instructor
Date
SOAP
SUBJECTIVE:
ID:
CC:
HISTORY OF PRESENT ILLNESS (HPI):
PAST MEDICAL HISTORY:
PAST MEDICAL PROCEDURES:
MEDICATIONS:
ALLERGIES:
FAMILY HISTORY:
Mom:
Dad:
Brother:
Sister:
Paternal grandpa:
Paternal grandma:
Maternal grandpa:
Maternal grandma:
SOCIAL HISTORY:
-SEXUAL/REPRODUCTIVE:
-TOBACCO USE/Vaping:
-ALCOHOL USE:
-DRUG USE:
-MARITAL HISTORY:
-OCCUPATION:
-EXERCISE/DIET:
-SLEEP/STRESS:
-HOUSING:
-SAFETY:
IMMUNIZATIONS:
SPIRITUAL:
SUICIDE/DEPRESSION:
ROS:
CONSTITUTIONAL:
INTEGUMENTARY:
HEAD, EYES, EARS, NOSE, THROAT:
RESPIRATORY:
NECK:
CARDIOVASCULAR:
GASTROINTESTINAL:
PERIPHERAL VASCULAR:
GENITOURINARY:
MUSCULOSKELETAL:
PSYCH:
NEURO:
HEMATOLOGIC:
ENDOCRINE:
ALLERGY/IMMUNOLOGY:
OBJECTIVE:
VITAL SIGNS:
P: BP: RR: T: SpO2 RA: Pain:
Ht: Wt: BMI:
PHYSICAL EXAM:
GENERAL survey:
HEENT:
NECK:
CHEST/BREAST:
RESPIRATORY:
CARDIOVASCULAR:
ABDOMEN/GI:
GASTROURINARY:
LYMPHATIC:
MUSCULOSKELETAL:
NEUROLOGIC:
PSYCHIATRIC:
SKIN:
PERIPHERAL VASCULAR:
ASSESSMENT:
1.
2.
3.
Final diagnosis:
PLAN:
Diagnostic labs:
Treatment/Therapeutic Plan (meds):
Education & F/U plan:
Referrals:
References
1.
2.
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