SOAP Note: HEENT
SOAP Note: HEENT (Head, Eyes,Ear, Nose and Throat)
State on your SOAP Note: HEENT that the patient consented before your documentation
- For your documentation this week, create a HEENT-related Chief Complaint. Create an ID, CC, HPI, ROS, V/S, physical findings, and assessment with at least three differential diagnoses, a final diagnosis, and a treatment plan in a SOAP note format.
- Use an HEENT-related CC that a patient would present within a primary care setting (i.e., no emergency room or ICU type complaints. Example: sore throat, earache, hearing loss, eye drainage, etc.).—–(SORE THROAT & RUNNY NOSE is ok for use for chief complaint)
- Include at least 3-4 references for your diagnostic and treatment plan. They should be recent (in the last 5-10 years) and peer-reviewed. Use APA title page, citations, and reference format.
- Ensure the treatment plan includes all components (diagnostic, therapeutic, education, and follow-up).
- Your document’s ROS and physical exam should be written as they would be for a problem-focused visit.
- The HEENT part of the physical exam should be comprehensive,
- Submit this SOAP note and the video in the assignment tab
Please see attached you tube link video, if you can listen to the SOAP note description section, that would help a lot in creating this problem-focused HEENT SOAP Note.
Please disregard the video section because it is for normal video recording. I also uploaded a sample worksheet of a SOAP Note as guidance. Thanks a lot!!!!
As always, I am counting on you on this paper writing.