Soap note Study guides, Class notes & Summaries
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NRNP 6675 Week 3 Focused SOAP Note and Patient Case Presentation
- Exam (elaborations) • 11 pages • 2022
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NRNP 6675 Week 3 Focused SOAP Note and Patient Case Presentation/NRNP 6675 Week 3 Focused SOAP Note and Patient Case Presentation/NRNP 6675 Week 3 Focused SOAP Note and Patient Case Presentation/NRNP 6675 Week 3 Focused SOAP Note and Patient Case Presentation
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OSC Ophthalmic Scribe Test | 100 Questions with 100% Correct Answers | Verified | Latest Update 2024
- Exam (elaborations) • 10 pages • 2024
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what is the primary function of a medical scribe? - create the medical note 
what is the preferred format for the creation of the medical note? - subjective, objective, 
assessment, plan (soap) 
"present time" pt details are summarized by using what format - OPQRST 
all current procedural terminology (CPT) codes must be justified by what appropiate coding mechanisms 
- international classification of disease (ICD) 
what patient history is outlined in the PMHx - medical history 
what scribing i...
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WOMEN’S HEALTH MINI SOAP NOTES
- Exam (elaborations) • 35 pages • 2024
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WOMEN’S HEALTH MINI SOAP NOTES 
 
A 25-year-old woman comes to the clinic complaining of increased vaginal discharge, milky gray in color with a "fishy" odor that both she and her husband have noticed. A wet smear is performed and the presence of "clue cells" confirmed. Which type of infection does the nurse suspect? 
1 
Candidiasis 
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Trichomoniasis 
3 
Bacterial vaginosis 
4 
Group B Streptococcus - ANS -Bacterial vaginosis 
 
Signs of bacterial vaginosis include a milky gray vaginal...
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HEENT SOAP NOTE with complete solution
- Exam (elaborations) • 9 pages • 2023
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HEENT SOAP NOTE with complete solution 
HEENT SOAP NOTE 
Jewel Concepcion 
United States University 
MSN 572 Advanced Physical Assessment 
Dr. Sherian Wilmot-Carter 
March 27, 2023
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NUR 5153 FNP SOAP note new template
- Other • 10 pages • 2024
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:Section 1 
Patient Initials: J.A. Age: 58 y/o Gender: Male Race: 
Caucasian 
”.Chief complaint: “I’ve been having some chest discomfort · 
 :HPI · 
 OLDCARTS o 
J.A. is a 58 y/o healthy man presenting to care provider with a o 
complaint of recent episodes of burning chest discomfort X 4 
days. Rating substernal pain 4-5/10 at its worst, radiating into his 
neck. Current pain of 1-2/10. Borderline-obese. Well controlled 
HTN, on Lopressor, and borderline lipid abnormality. Recent 
stres...
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Carolyn Cross V2VE SOAP NOTE: I-Humane Assessment
- Case • 16 pages • 2024
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Name: Carolyn Cross	Date: 3/18/2017	Time: 21:00am 
elmdtn Patient Encounter # 
 
4140505	Age: 41 years	Sex: Female 
CC: This 41-year-old male presents a chronic cough. She said, “My throat is painful, I cough frequently. There seems to be nothing to relieve it when I started to cough.” 
HPI: Carolyn Cross confirms that coughing started almost four weeks ago after failing to wear a sweater, during one cold morning when attending a job. Carolyn Cross added that chronic coughing started one wee...
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NURS 3150 soap note Fall 2023
- Other • 9 pages • 2023
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NURS 3150 soap note Fall 2023 
 
Subjective Data 
A. Chief Complain (CC): “I need a primary care doctor and I also have an injury to 
my toe” 
B. History of Present Illness (HPI): 
C. Last Menstrual Period– Not applicable. 
D. Allergies: NKDA 
E. Past Medical History: Hypertension and diabetes II 
F. Family History: Father – Diabetes and Glaucoma 
 Mother – Hypertension 
G. Surgery History- None 
H. Social History- Denies drug use, alcohol and tobacco use, Erickson 
developmental stage...
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NRNP 6665 Assignment 2 Focused SOAP Note and Patient Case Presentation, NRNP 6665 PMHNP Care Across the Lifespan I, Walden University.
- Exam (elaborations) • 12 pages • 2024
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NRNP 6665 Assignment 2 Focused SOAP Note and Patient Case Presentation, NRNP 6665 PMHNP Care Across the Lifespan I, Walden University.
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NRNP 6552 Wk3Assgn2,Case study (Walden university)
- Case • 22 pages • 2023
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NRNP 6552 Wk3Assgn2,Case study (Walden university) 
Case Study 2 
 
Case Study: STI Investigation 
 
Susan Lang is a 24-year-old Caucasian female presenting to the clinic for regular care. She works full- time as an administrative assistant, and relates she loves her job. She has no medical or surgical history, takes no medication, and has no allergies. Family history is non-contributary. Social history is remarkable for cigarette smoking at a rate of ½ packs per day (PPD) since age 14, / EtOH ...
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EYoung Cardiovascular SOAP Note Harvey Hoya Graded A+
- Exam (elaborations) • 2 pages • 2022
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EYoung Cardiovascular SOAP Note Harvey Hoya Graded A+ 
SOap Note Blue Print 
Course: NURS5102R50 Student: Emily Young Faculty: Dr. Tracy Collins 
Pt Initials: HH Age: 57 Race: Hispanic Sex: M New Pt: Y Established Pt: 
Info Source: Patient Reliability: Reliable E&M Code(s) I.10 
S CC: Elevated blood pressure 
HPI: A 57-year-old Hispanic male presents to the clinic “I had my blood pressure checked at a health fair earlier 
and it was high, my wife convinced me to come in.” Patient describes a...
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