SOAP NOTE: Construction Worker Patient

52-year-old male who is a construction worker who came to the clinic with symptoms on his right knee associated with a fall that he sustained a week ago while coming down the stairs.

Create a SOAP NOTE and follow the soap note format attached

ORDER CUSTOM, PLAGIARISM-FREE PAPER

Patient Initials:

Pt. Encounter Number:

Date:

Age:

Sex:

Allergies: Advanced Directives:

SUBJECTIVE

CC:

HPI: Describe the course of the patient’s illness:

Onset:

Location:

Duration:

Characteristics:

Aggravating Factors:

Relieving Factors:

Treatment:

Current Medications:

PMH

Medication Intolerances:

Chronic Illnesses/Major traumas:

Screening Hx/Immunizations Hx:

Hospitalizations/Surgeries:

Family History:

Social History:

ROS

General

Cardiovascular

Skin

Respiratory

Eyes

Gastrointestinal

Ears

Genitourinary/Gynecological

SOAP NOTE

Nose/Mouth/Throat

Musculoskeletal

Breast

Neurological

Heme/Lymph/Endo

Psychiatric

OBJECTIVE

Weight BMI

Temp

Height

Pulse

Resp

PHYSICAL EXAMINATION

General Appearance

Skin

HEENT

Cardiovascular

Respiratory

Gastrointestinal

Breast

Genitourinary

Musculoskeletal

Neurological

Psychiatric

Lab Tests

Special Tests

Diagnosis

· Primary Diagnosis-

 Evidence for primary diagnosis should be documented in your Subjective and

Objective exams.

o Differential Diagnoses–

PLAN including education

o Plan:

 Further testing

 Medication

 Education

 Non-medication treatments

· Referrals

 Follow-up visits

References

ADDITIONAL INSTRUCTIONS FOR THE CLASS

Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.

Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

APA Format and Writing Quality

Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.