HYPOTHYROIDISM SOAP NOTE

Hypothyroidism SOAP NOTE

Patient Initials: Age: Gender:

SUBJECTIVE DATA:

Chief Complaint (CC): “ ”.

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Current medication:

Past Surgical History (PSH):

Family History:

Personal/Social History:

Immunization: up to date.

Lifestyle:

Review of Systems:

General:

HEENT:

Neck:

Breasts:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Psychiatric:

Neurological

Skin:

Hematologic:

Endocrine:

OBJECTIVE DATA:

Physical Exam:

Vital signs: Temperature: ; BP: mmHg; HR: bpm; RR: /min; Oxygen Saturation: %; Pain: (0-10 scale), Weight lb; Height; BMI

General:.

HEENT:

Neck:

Chest

Lungs:

Heart:

Peripheral Vascular:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

ASSESSMENT:

Differential Diagnosis

1. Hyperthyroidism.

2.

3.

From both the subjective and objective data, it is clear that the main diagnosis is

PLAN:

Treatment Plan: (please prescription with dose)

Non-pharmacological approaches

For the follow-up, the patient should get back to the hospital after

References: 2 or 3 with APA format

Soap Note 2 Chronic Conditions (15 Points)

Pick any Chronic Disease from Weeks 6-10

Follow the MRU Soap Note Rubric as a guide:

Use APA format and must include minimum of 2 Scholarly Citations.

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.

Please use the sample templates for you soap note, keep these templates for when you start clinicals.

The use of templates is ok with regards of Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.

The Systems Development Life Cycle And The Nurse Informaticist

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