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Nws1559599904 adultone 1 soaptemplate spring2015 1

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SOAP Note Form
S/ Identifying Information: (initials, age/DOB, gender, reliability)
Family Hx:
SOAP is an abbreviation for Subjective, Objective, Assessment and Plan
which refers to a structured and organized way of documentation for
healthcare providers. The method was established by Larry Weed 50 years
ago. Its objective was to aid healthcare providers with a clinical reasoning
by providing them with a cognitive framework. It also provides a framework
for evaluating information by helping clinicians to perform specific tasks.
This paper will discuss A.J’s diagnosis and treatment using SOAP note.
Personal/Social
Hx:
Chief Complaint/RFE:
This are the chief complaints recorded by the healthcare provider as stated
by the patient or by the relative accompanying the patient to the hospital.
They vary depending with the kind of illness that a person is suffering from.
The following are A.J’s chief complaints:
1. The injury is painful at night at night and worse when she is up at
night with pain.
2. She has difficulties bending the knee when the brace gets off.
3. Frustration with the injury and wants it to get better so that she can
go back to practice.
4. Difficulties moving around.
5. Got injured a year ago but there no broken bones to injuries.
6. No allergies.
7. Sadness and very temperament as a result of the injury.

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8. Lack of sleep caused by extreme pain.
9. Dad has high tension and high stressful job.
Hx Present Illness: (7 Variables but do not list as such)
CURRENT HEALTH
Medications: X-ray tests: Fractures are assessed using x-rays.
CT scans are also used in the assessment of bony injuries.
Soft tissue damage are evaluated using MRIs.
There is also bending of the knee to check the stability and damage of the cartilages.
Allergies: These are the signs and symptoms that have been confirmed to be present. For A.J’s
situation, they include;
Pain
Sadness
Depression
Hypertension
Sleeping problems
Obesity
Seizures in the family

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SOAP Note Form Family Hx: S/ Identifying Information: (initials, age/DOB, gender, reliability) SOAP is an abbreviation for Subjective, Objective, Assessment and Plan which refers to a structured and organized way of documentation for healthcare providers. The method was established by Larry Weed 50 years ago. Its objective was to aid healthcare providers with a clinical reasoning by providing them with a cognitive framework. It also provides a framework for evaluating information by helping clinicians to perform specific tasks. This paper will discuss A.J’s diagnosis and treatment using SOAP note. Personal/Social Hx: Chief Complaint/RFE: This are the chief complaints recorded by the healthcare provider as stated by the patient or by the relative accompanying the patient to the hospital. They vary depending with the kind of illness that a person is suffering from. The following are A.J’s chief complaints: 1. The injury is painful at night at night and worse when she is up at night with pain. 2. She has difficulties bending the knee when the brace gets off. 3. Frustration with the injury and wants it to get better so that she can go back to practice. 4. Difficulties moving around. 5. Got injured a year ago but there no broken bones to injuries. 6. No allergies. 7. Sadness and very temperament as a result of the injury. 8. Lack of sleep caused by extreme pain. 9. Dad has high tension and high stressful job. Hx Present Illness: (7 Variables but do not list as such) CU ...
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