PROBLEM-FOCUSED NOTE
\n36-year-old female G1P1 LMP 10\/1\/2021
\nPainful menses each month. No relief with OTC pain medications
\nSexually active with 2 male partners. Painful intercourse
\nDoes not use condoms
\nSevere pain at ovulation
\nSubjective Data
\nHPI
\nMed History \u2013 make up answers for her.
\nSocial Hx
\nFamily Hx
\nUse OLDCART
\nInclude ROS
\nObjective Data
\nInclude vital signs
\nInclude point of care testing (POCT) (if appropriate)
\nInclude an appropriate exam
\nAssessment
\nInclude ICD 10 code
\nInclude DDX
\nPlan
\nInclude medication (if appropriate)
\nInclude education, teaching, follow-up, and referral (if appropriate)<\/p>\n
Problem-Focused SOAP Note Format
\nDemographic data
\nPatient initial (one initial only), age, and gender must be HIPAA compliant.
\nSubjective
\nChief Complaint (CC)
\nHistory of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating\/Alleviating Factors, Relieving Factors, Treatment)
\nPast Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance
\nFamily Hx
\nSocial Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
\nReview of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
\nObjective
\nPhysical findings listed by body systems, not paragraph form
\nAssessment (the diagnosis)
\nThree (3) differential diagnoses (if applicable) with rationale
\nFinal diagnosis with rationale and pathophysiological explanation
\nPlan
\nDx Plan (lab, x-ray)
\nTx Plan (meds)
\nPt. Education, including specific medication teaching points
\nReferral\/Follow-up
\nHealth maintenance (including when screenings, immunizations, etc., are next due):
\nReference
\nCompare care given to the patient with the National Standards of Care\/National Guidelines. Cite accordingly.
\nEXAMPLES ARE LISTED BELOW!!!!!<\/p>\n","protected":false},"excerpt":{"rendered":"
PROBLEM-FOCUSED NOTE 36-year-old female G1P1 LMP 10\/1\/2021 Painful menses each month. No relief with OTC pain medications Sexually active with 2 male partners. Painful intercourse\u2026<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[10099,10681,7636,615,10892,10680,10891],"tags":[10553,10616,10254,10896,10897,10247,10295,10898,10893,10894,10895,10899,10551],"class_list":["post-127573","post","type-post","status-publish","format-standard","hentry","category-buy-essay","category-cheap-dissertation-help-online","category-cheap-essay-writer-usa","category-homework-help-writing-service-usa","category-page-paper","category-university-dissertation-writing-service","category-write-my-assignment-ireland","tag-1-assignment-help-online-service-for-students-in-the-usa","tag-australian-best-tutors","tag-can-someone-write-my-assignment-for-me","tag-case-study-in-nursing-writing-a-nursing-case-study-essay","tag-free-nursing-case-studies","tag-help-me-write-my-dissertation","tag-homework-for-you","tag-nursing-case-study-assignment-examples","tag-nursing-case-study-examples","tag-nursing-case-study-presentation-example","tag-nursing-case-study-questions-and-answers","tag-student-nurse-case-study-assignments","tag-write-my-assignment-help-for-college-students"],"_links":{"self":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/posts\/127573","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/comments?post=127573"}],"version-history":[{"count":0,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/posts\/127573\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/media?parent=127573"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/categories?post=127573"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/tags?post=127573"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}