SOAP Note week 2.doc{latest 2021|2022 graded A+}

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SOAP Note Name (Initials): R. P. Date: 11/7/2018 Time: 1000 Age: 38 Sex: F SUBJECTIVE Data Chief Complaint (CC): Reason given by the patient for seeking medical care “in quotes” “I am here... today because I think I have a yeast infection. I am having discharge and itching.” History of Present Illness (HPI): Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness. Include the 7 attributes of the symptoms: Location, quality, quantity/sverity, timing, remitting/exacerbating, factors, associated manifestations. Began about 1 week ago. No pain just itching very bad with discharge. “It has begun to burn when I urinate from the itching. Scratching makes it worse and I have tried not to but cant help it. Nothing makes it feel better. I tried using monostat cream but it didn’t help.” Medications: (Name of the medication, route, dosage, and reason for med ) Orthotricycline PO for birth control daily. Medication Intolerances: N/A Past Medical History (PMH) Allergies (Drugs, Food, and Environmental): N/A Tobacco, alcohol, or illicit drug use in the past: Drinks an occasional glass of wine socially with friends. Denies smoking or substance abuse. Chronic Illnesses/Major traumas: N/A [Show More]

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