This is an assignment that focuses on creation of SOAP NOTE on a patient with Hypothyroidism. The paper will also focus on the social history and also medical history.
Firstly, create a 2 page SOAP NOTE on a patient who has Hypothyroidism. You would will also need to create ALL of the INFORMATION that goes in the SOAP Note that would be associated with a person who has Hypothyroidism. Please write your plan as Nurse Practitioner who works in primary care. I have uploaded an EXAMPLE of the Typhon Documentation that out instructor requires for us to upload every week for clinicals, so it can assist you with writing this SOAP Note.
CC: chief complaint – What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.
HPI: history of present illness – use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]
The HPI would flow better if you use oldcart information in paragraph form using complete sentences
PMH: past medical history – This should also include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.
Allergies: State the offending medication/food and the reactions.
Medications: Names, dosages, and routes of administration.
Social history: Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work, and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.
Family history: Additionally, use terms like maternal, paternal, and the diseases and the ages they were deceased or diagnosed if known.
Health Maintenance/Promotion – Required for all SOAP notes: Immunizations, exercise, diet, etc. However, remember to use the United States Clinical Preventative Services Task Force (USPSTF) guidelines for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines.
ROS: review of systems – [Refer to your course modules and also the Bickley Etext (Bates Guide) as a guide when conducting your ROS to make sure you have not missed any important symptoms, particularly in areas that you have not already thoroughly explored while discussing the history of present illness.]
Additionally, ROS would be easier to read if you don’t run all systems together. Start each system on a new line.
You would also want to include any pertinent negatives or positives that would help with your differential diagnosis. For acute episodic (focused) visits (i.e. sprained ankle, sore throat, etc.) you may be omitting certain areas such as GYN, Rectal, GI/Abd, etc.
General: May include if patient has had a fever, chills, fatigue, malaise, etc.
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