Family Medicine SOAP (Multiple Issues)

Struktur der Vorlage

Dies ist die Struktur, der Notat folgt, wenn es die Notiz des Besuchs schreibt — Sie müssen sie nie von Hand ausfüllen.

Subjective:
(Include relevant history and associated information in chronological order)
1) [Chief complaint 1]
- [Hyphenated list of symptoms and related history]

2) [Chief complaint 2]
- [Hyphenated list of symptoms and related history]

etc...

Objective:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [Physical exam findings and/or mental status exam findings] (Format as "System: Exam findings", one system per line. Specify anatomical location if relevant)
- [Investigation results with units] (Only include completed investigations, otherwise leave blank. All planned or ordered investigations should be included under Plan)

Assessment & Plan:
(Do not fabricate the assessment and plan unless mentioned in the source material. Use medical terminology if appropriate. Each assessment and plan number should correlate directly with the subjective section. Include follow up instructions and return precautions if mentioned.)

1) [Diagnosis 1 and rationale if mentioned]
- [Hyphenated plan]

2) [Diagnosis 2 and rationale if mentioned]
- [Hyphenated plan]

etc…