Create a SOAP NOTE using the guidelines and template provided below.
Topic: I have been having pain in my pelvis area for the past month, my last menstrual period was 7 months ago but I have been spotting.
Primary diagnosis: Endometrial cancer
| Name: EC | Date: | Time: | ||
| Age: 47 years | Sex: Female | |||
| SUBJECTIVE | ||||
| CC: I have been having pain in my pelvis area for the past month, my last menstrual periods was 7 month ago but I have been spotting. | ||||
| HPI: (Use OLD CARTS tool) | ||||
| Medications: | ||||
| PMH: Allergies: Medication Intolerances: Immunizations: Chronic Illnesses/Major traumas: Hospitalizations/Surgeries (include delivery of pregnancies here) | ||||
| Family History | ||||
| Social History | ||||
| ROS | ||||
| General | Cardiovascular | |||
| Skin | Respiratory | |||
| Eyes | Gastrointestinal | |||
| Ears | Genitourinary/Gynecological | |||
| Nose/Mouth/Throat | Musculoskeletal | |||
| Breast | Neurological | |||
| Heme/Lymph/Endo | Psychiatric | |||
| OBJECTIVE | ||||
| Weight: BMI: | Temp: | BP: | ||
| Height: | Pulse: | Resp: | ||
| General Appearance | ||||
| Skin | ||||
| HEENT | ||||
| Cardiovascular | ||||
| Respiratory | ||||
| Gastrointestinal | ||||
| Breast | ||||
| Genitourinary | ||||
| Musculoskeletal | ||||
| Neurological | ||||
| Psychiatric | ||||
| Lab Tests (list the results if you have them) | ||||
| Special Tests (done or ordered during the OV) No special tests ordered. | ||||
| Diagnosis – include the appropriate ICD – 10 Code for each diagnosis used | ||||
| Primary Diagnosis Differential Diagnoses (these must be different from the Primary Diagnosis) | ||||
| Plan/Therapeutics (explain fully) | ||||
| Evaluation of patient encounter | ||||
References
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