scabies.Soap Note
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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