Diabetic SOAP
Använd den här mallen i NotatSkapa ett konto eller logga in. Granska sedan mallen och spara den i ditt bibliotek.
Exempel på färdig anteckning
Se hur formatet fungerar i praktiken. Den återanvändbara mallen och de kliniska fakta som ligger till grund för anteckningen finns nedan.
Färdig anteckning
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.
Illustrativt fall med påhittade patientuppgifter. Detta är inte en riktig patientjournal eller klinisk vägledning. Granska varje anteckning mot din egen konsultation.
Använd den här mallen i NotatKliniska fakta bakom anteckningen
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
Återanvändbar mallstruktur
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
Din konsultation. Det här anteckningsformatet.
Spara en egen kopia av mallen, anpassa strukturen och spela in konsultationen. Notat extraherar först de kliniska fakta. Sedan skriver FactsContext™-motorn anteckningen utifrån dessa fakta, så att du kan kontrollera underlaget innan du redigerar och signerar.
Använd den här mallen i NotatAnvänd det här formatet vid din nästa konsultation
Behåll strukturen. Låt Notat skriva anteckningen utifrån din konsultation och granska och redigera den sedan.
Använd den här mallen i NotatSkapa ett konto eller logga in. Granska sedan mallen och spara den i ditt bibliotek.