scabies.Soap Note

SOAP NOTE SAMPLE FORMAT FOR MRC

Name:  Date: Time:
  Age: Sex:
SUBJECTIVE
CC:  “ .”
HPI:  .  
Current Medications:  
PMHx: Allergies:     Medication Intolerances: Chronic Illnesses/Major traumas   Hospitalizations/Surgeries  
Family History  
Social History  
ROS
General Cardiovascular  
Skin   Respiratory  
Eyes   Gastrointestinal  
Ears   Genitourinary/Gynecological  
Nose/Mouth/Throat  
Breast Neurological
Heme/Lymph/Endo Psychiatric
OBJECTIVE
Weight   lb Temp BP
Height 5’1 Pulse Respiration
General Appearance
Skin
HEENT
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal Full ROM seen in all 4 extremities as patient moved about the exam room.
Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Psychiatric Alert and oriented. Dressed in clean clothes. Maintains eye contact. Answers questions appropriately.
Lab Tests  
Special Tests- No ordered at this time.  
 Diagnosis
 Differential Diagnoses Diagnosis
Plan/Therapeutics
· Plan:  · Medication – · Education – · Follow-up

References

 
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