Transaction Register Algebra Questions

(Student Name)                                       APA format

University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor:

Soap Note # ____

Main Diagnosis

______________

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:

Symptom analysis/HPI:

The patient is …

Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

MUSCULOSKELETAL:

SKIN:

Objective Data:

VITAL SIGNS:

GENERAL APPREARANCE:

NEUROLOGIC:HEENT:CARDIOVASCULAR:RESPIRATORY:GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:

ASSESSMENT:

(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.)

Main Diagnosis

(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 6th or 7th Edition.

Differential diagnosis (minimum 3)

—

PLAN:

Labs and Diagnostic Test to be ordered (if applicable)

–

–

Pharmacological treatment:

–

Non-Pharmacologic treatment:

Education (provide the most relevant ones tailored to your patient)

   Assignment # 14. Examples and work. Chapter 2. Checking
Account.
Example: