Diabetic SOAP
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Exemplo de nota preenchida
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Nota preenchida
S: Here today for diabetes follow-up. Reports feeling well overall and no medication changes since the last visit. Denies symptomatic low glucose episodes. Patient currently taking metformin 500 mg orally twice daily. O/E BP: 128/76 mmHg Please see diabetes flow sheet below. A1C: 7.6%, increased from 7.2%. LDL: 92 mg/dL, decreased from 101 mg/dL. HDL: 48 mg/dL, unchanged from 48 mg/dL. Wt: 82 kg, increased from 80 kg. A: Diabetes under suboptimal control based on A1C trend. LDL near target; continue monitoring. Weight up from last appointment. BP is at target. Reviewed current medication routine and home glucose monitoring. P: Advised to continue a balanced diabetic diet and regular activity as tolerated. Continue current medication regime; no adjustment made today. Discussed recording home readings and bringing them to the next visit. Will see back in three months for a diabetes visit. Return sooner with persistent high or low readings or other concerns.
Caso ilustrativo com dados de paciente inventados. Não é um registo real de paciente nem orientação clínica. Reveja cada nota à luz da sua própria consulta.
Utilize este modelo no NotatFactos clínicos por trás da nota
chief complaint
Routine diabetes follow-up
denials of symptoms
No symptomatic hypoglycemia
medications
Metformin 500 mg twice daily
vital signs
Blood pressure 128/76 mmHg
assessment
A1C 7.6%, increased from 7.2%
LDL 92 mg/dL, decreased from 101 mg/dL
Weight increased by 2 kg
plan
Continue current medication and follow up in three months
Estrutura reutilizável do modelo
S: Here today for diabetes visit. No changes in medication since last seen. Over all feels doing well. Patient currently taking (add diabetic medication) O/E BP: Please see diabetes flow sheet below A1C: [current A1C] increased/decreased from [previous A1C] LDL: [current LDL] increased/decreased from [previous LDL] HDL: [current HDL] increased/decreased from [ previous HDL] Wt: [current wt in kilograms ] increased/decreased from [previous wt in kilograms ] A: Diabetes under good/sub optimal control LDL at target/not at target Weight up/down from last apt BP is at/not at target Discussed insulin regime in detail P: Advised to continue with diabetic diet/exercise etc I have advised to continue with current medication regime I have added the following medications to current regime: I will see back in 3/6 months for diabetic visit See sooner with any other concerns
A sua consulta. Este formato de nota.
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Utilize este modelo no NotatCrie uma conta ou inicie sessão; depois reveja e guarde este modelo na sua biblioteca.