Soap Note For Patient With Psoriasis (24 Hours)

1) ************Complete the template attached (See File 1) according to the example (See File 2 )

It is mandatory that you respect the information requested in the template

You should not modify the template. The titles and subtitles will be verified

 

2)¨******APA norms

Dont write in the first person

Dont copy and pase the questions.

Answer the question objectively, do not make introductions to your answers, answer it when you start the paragraph

 

3) It will be verified by Turnitin and SafeAssign

 

4) Minimum 5 references not older than 5 years

 

 

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Purpose: create soap note for patient with Psoriasis

 

Create a clinical case of a patient diagnosed with Psoriasis. Based on the case you created, complete the Template

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor:

Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Psoriasis)

PATIENT INFORMATION

Name:

Age:

Gender at Birth:

Gender Identity:

Source:

Allergies:

Current Medications:

·

PMH:

Immunizations:

Preventive Care:

Surgical History:

Family History:

Social History:

Sexual Orientation:

Nutrition History:

Subjective Data:

Chief Complaint: “XXX”

Symptom analysis/HPI:

Review of Systems (ROS)

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL:

SKIN:

Objective Data:

VITAL SIGNS:

GENERAL APPREARANCE:

NEUROLOGIC:

HEENT:

Head:

Neck:

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:

ASSESSMENT:

Main Diagnosis:

Differential diagnosis:

·

PLAN:

Labs and Diagnostic Test to be ordered:

·

Pharmacological treatment:

·

Non-Pharmacologic treatment:

·

Education

·

Follow-ups/Referrals

·

References

Evidence Based PracticeEvidence Based Practice