Discussion Topic: Soap Note 1 "ADULT" Wellness check up
– The discussion must address the topic
– Rationale must be provided
– Use at least 600 words (no included 1st page or references in the 600 words)
– May use examples from your nursing practice
– Formatted and cited in current APA 7
– Use 3 academic sources, not older than 5 years. Not Websites are allowed.
– Plagiarism is NOT permitted
Soap Note # ____ Main Diagnosis ______________
Gender at Birth:
The patient is …
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 7th Edition.
Differential diagnosis (minimum 4)
Labs and Diagnostic Test to be ordered (if applicable)
Education (provide the most relevant ones tailored to your patient)
References (in APA Style)
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