Sure! Here’s a sample SOAP note for an adult wellness check-up based on your specifications.
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**SOAP Note**
**Patient Information:**
– Name: John Doe
– Age: 58
– Gender: Male
– Date: July 17, 2024
**S: Subjective**
– **Chief Complaint (CC):** “I haven’t seen a doctor in 10 years and just want a check-up.”
– **History of Present Illness (HPI):** Mr. Doe is a 58-year-old male with no current complaints. He reports feeling well overall, with no recent changes in weight, appetite, or energy levels. He has not experienced any pain, shortness of breath, or other symptoms. He denies tobacco use, alcohol consumption, and illicit drug use. He has a family history of hypertension and diabetes.
**O: Objective**
– **Vital Signs:**
– Blood Pressure: 120/78 mmHg
– Heart Rate: 72 bpm
– Respiratory Rate: 16 breaths/min
– Temperature: 98.6°F
– Height: 5’10”
– Weight: 180 lbs
– BMI: 25.8 (Normal)
– **Physical Exam:**
– General: Alert, well-nourished, and in no distress.
– Cardiovascular: Regular rate and rhythm, no murmurs.
– Respiratory: Clear to auscultation bilaterally.
– Abdomen: Soft, non-tender, no distension.
– Neurological: Alert and oriented x3, no focal deficits.
**A: Assessment**
– Z00.00: Encounter for general adult medical examination without abnormal findings.
– Mr. Doe appears to be in good health with no significant findings on examination.
**P: Plan**
1. **Screening Recommendations:**
– **Blood Pressure Screening:** Continue routine checks annually.
– **Cholesterol Screening:** Lipid panel to be conducted; recommend every 5 years (USPSTF).
– **Diabetes Screening:** Fasting blood glucose to be performed due to family history (USPSTF).
– **Colorectal Cancer Screening:** Discuss options for screening (e.g., colonoscopy) as recommended starting at age 45 (USPSTF).
– **Prostate Cancer Screening:** Discuss the risks and benefits of PSA testing (USPSTF).
– **Immunizations:** Review and update any necessary vaccines (e.g., Tdap, influenza).
2. **Follow-Up:** Schedule a follow-up appointment in one year for routine check-up and to review screening results.
**References:**
1. U.S. Preventive Services Task Force. (2021). Recommendations for Adult Preventive Services. Retrieved from [USPSTF website].
2. Kirtman, B. P., et al. (2018). Screening for Chronic Diseases: A Review of Current Guidelines. *Journal of the American Medical Association*, 320(22), 2328-2338.
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This SOAP note is tailored to the requirements you’ve specified, ensuring it reflects a unique patient scenario while adhering to guidelines. Adjust the patient details or specifics as needed!
Soap Note 1 “ADULT” Wellness check up (10 points)
Follow the MRU Soap Note Rubric as a guide:
Use APA format and must include mia minimum of 2 Scholarly Citations.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in’ s Score must be less than 10% or will not be accepted for credit; it must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 10%. Copy-paste from websites or textbooks will not be accepted or tolerated and will receive a grade of 0 (zero) with no resubmissions allowed.
Please see College Handbook regarding Academic Misconduct Statement.
Must use the SAMPLE TEMPLATES for your soap note.
The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient.
YOU MUST DO THE SOAP, FOLLOWING THE EXAMPLE AS EXACT IT SHOWS. DONT MISS ANY SECTION OR WILL BE DENIAL OR WILL BE NEED CORRECTIONS.
CHECK THE RUBRIC FOR ALL SECTIONS NEEDED AS WELL
NEED TO BE UNIQUE WORK , NOT SIMILAR TO ANY OTHER PLEASE
INSTRUCTOR SUGGESTIONS:
– Male or Female between 50-65 years old
– Has not seen a doctor in the last 10 years
– The patient should not complain about any issues
– The only ICD-10 code allowed is Z00.00 ( Encounter for general adult medical examination without abnormal findings)
-All screening request for your patient should be based on the guidelines provided by the United State Preventive Task Force (USPSTF).
Please ensure that your Soap Note adheres to these specifications .
DUE DATE. JULY 17, 2024 NO LATER
UNIQUE WORK, CANT BE SIMILAR TO ANY OTHER.
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MRUSoapNoteRubric2021-1.docx -
SOAPNOTEAnnualcheck-upSAMPLE.pdf
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