Comprehensive Health Assessment

Select a patient that you examined during the last four weeks. With this patient in mind, address the following in a SOAP Note:

  • Subjective: What details did the patient provide regarding or her personal and medical history?
  • Objective: What observations did you make during the physical assessment?
  • Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
  • Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
  • Reflection notes: What would you do differently in a similar patient evaluation?

(THE TOPIC HERE IS URINARY TRACT INFECTION (UTI) )

please use this format

 

Comprehensive SOAP Template

Patient Initials:  Age:  Gender: F

Introduction –Purpose:

SUBJECTIVE DATA: 

Chief Complaint (CC):

History of Present Illness (HPI): 

Medications: 

Allergies: Seafood, iodine

Past Medical History (PMH):

Past Surgical History (PSH): Denies.

Sexual/Reproductive History (Obstetric):

Personal/Social History:

Immunization History and Preventive Care: 

Significant Family History:

.

Review of Systems: 

General:

HEENT:

Respiratory:

Cardiovascular:

Breasts: 

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Psychiatric:

Neurological:

Dermatological:

Hematological and Lymphatic:

Endocrine:

Allergy and Immunology:

OBJECTIVE DATA: 

Physical Exam:

Vital signs:

General appearance:

HEENT: 

Neck: 

Lymphatics: 

Breasts: 

Chest:

Heart: 

Abdomen: 

Neurological:

Musculoskeletal:

Extremities:

Skin:

Labs, X-rays, and Diagnostics

ASSESSMENT:

Priority Diagnosis 

Differential Diagnosis

For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.

PLAN:

Treatment Plan: If applicable, include both pharmacological and non-pharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.

Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.

Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.

REFLECTION:Reflect on your clinical experience, and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence?

 

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