Family Medicine SOAP (Multiple Issues)

Nota finalizada

Ejemplo — generado por Notat a partir de una visita de muestra

Presenting concern:
Intermittent lower back pain after lifting boxes at work five days ago. No leg weakness, numbness, bladder or bowel symptoms.

Assessment:
Mechanical low back pain without features of nerve root involvement.

Plan:
Encouraged gentle activity and simple analgesia as needed. Discussed return precautions and review in two weeks if not improving.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Plantilla

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…