Category: Uncategorized

Female 25 year old, 26 weeks pregnant feeling light headed BP 170/100 ,no previous history of HTN looks like hypertensive crisis pre eclampsia eclampsia has to go to ERTYPE OF SOAP NOTEDATESOAP NoteCC:HPI:Allergies:Social History:Medications:Past Surgical History:Family History:ROS:General:Skin:.Head:Eyes:Ears:Nose/ Sinus:Mouth/ Throat:Neck:Pulmonary:Cardiac:GI:Urinary:Peripheral Vascular:Musculoskeletal:Neuro:Heme:Endo:Psych:Objective:Vital Signs: BP: , HR: , RR: , Temp: , BMI (normal/overweight)General:Skin:HEENT:Neck & Lymph:Thorax & LungsCV:Abdomen:Musculoskeletal:Neuro:Psychiatric:In office lab results/Point of care testing:Assessment/Diagnosis: (include your rationale)1. ICD10 code + diagnosis + rationale2. ICD10 code + diagnosis + rationalePlan: Diagnostics1. Order labs: (List labs and rationale why for each lab ordered)2. Order Imaging: (List what tests would you order and why)2. Referrals:Plan: Intervention1. (List appropriate therapeutic interventions (pharm & non-pharm) based on current evidence) Include medication, name, dose, number given, route, frequency, length of time and number of refills prescribed for all medications. Include orders for referral to other therapeutic modalities.Plan: Education––––Plan: Follow up1.2.3.3 Differential Diagnosis + Pathophysiology + Rationale for accepting or rejecting diagnoses.1. ICD10 code – Diagnosis– Pathophysiology:– Rationale:2. ICD10 code – Diagnosis– Pathophysiology– Rationale:3. ICD10 code – Diagnosis– Pathophysiology– Rationale:4. Next steps (Based upon the pathophysiology of the diagnosis and expected findings from the literature, indicate if additional history, exam, diagnostics/ labs/or time are yet needed to make a firm diagnosis).5. Discussion1.Guideline Selection and ComparisonGuidelines used for this visit:Reflection:Inter-professional POC:

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