Progress Note SOAP Format Describe in detail the patient: Name, age, gender, & profession any other information you want to provide which might be helpful to determine the diagnosis. -Patient is Renee Shelton, 17 yr old female student -Generally good health, Hx shows heart, lungs, kidneys normal -Mother, three sisters, three brothers AAW Subjective: This is everything that the patient describes ( you may also want to research to see what other symptoms patient may have had for the diagnosis ) -CC: Syncopy and dizziness -Hx: No major heart, lung, kidney, or abdominal issues. Smoker, ½ ppd, occasional ETOH, On brith control for 6/mo. -ROS: Denies drug use. Complaints of discomfort in L arm and R leg, no erythema, laceration, abrasions, or swelling. Objective: This is the diagnosis of the patient – find the diagnosis listed as the admission diagnosis if the discharge diagnosis different from the admission diagnosis write both here. -PE: Slightly overweight, NAD. EENT unremarkable. Vitals: T 98.6, HR 88, RR 20, BP 133/70 sitting, 120/70 lying down. Alert, active cooperative, oriented. CN 2-12 intact. DTR +2 and symmetrical. No clonus. Toes down going bilaterally. Muscle tone and strength normal. -Dx Tests: ECG and SCG WNL. Ca 9.5, Cr .9, TP 6.6, Albumin 4.0. Blood work WNL. WBC 8,700, 55 segmented cells, 34 lympocytes, 10 monocytes, 1 eosinophils. Hgb 13. UA WNL. Assessment: All labs, test and any procedure done to make an assessment for the diagnosis -Syncopy episodes of unknown etimology. R/O seizure disorder. Normal ECG, SCG II, blood chemistry, CBC and UA. Plan ; What plan does the patient have include referrals, medications etc… -Tx: Tylenol,Valium 5mg q10 p.r.n. seizures or agitation - Instructed to reduce activity, cease smoking. Schedules outpatient EEG (sleep deprived, hyperventilates,) avoid OTC cold premedies pre EEG. Possible refer to neurologist. Progress Note SOAP Format ONLY use this format – this is a word documents – if I can’t download the file, I can’t grade you.
