hypertension soap note example

Mr. S is retired and lives with his 56 years old wife who runs a, grocery store and 28 years old daughter. David states that he continues to experience cravings for heroin. David remains aroused and distractible, but his concentration has improved. No sign of substance use was present. Social History: Negative for use of alcohol or tobacco. These templates are typically in word or PDF format, so you can easily make changes to them. tolerance. Repeat for additional problems, State which testing is needed and the rationale for choosing each test to resolve diagnostic ambiguities; ideally what the next step would be if positive or negative. SOAP notes for Epilepsy 10. Internal consistency. From taking a yoga class together to hosting a game night, these activities will help you take care of yourself. Sample Name: Diabetes Mellitus - SOAP Note - 1 this patient was easy despite having a language barrier. ( If you are looking for additional features, the Professional Plan is $12/month and the Organization Plan is $19/month., TherapyNotes is a platform that offers documentation templates, including SOAP, to healthcare practitioners. : Diagnosis is grounded on the clinical assessment through history, physical examination, and, routine laboratory tests to evaluate the risk factors, reveal any abnormal readings, including. HPI: 35 y/o male presents to clinic stating his home blood Anxiety 2. A possible trigger to her poor control of HTN may be her alcohol use or the presence of obesity. no noted masses. SOAP notes for Hypertension 2. General diet. SOAP notes are an essential piece of information about the health status of the patient as well as a communication document between health professionals. Even though SOAP notes are a simple way to record your progress notes, it's still helpful to have an example or template to use. To continue DT and TRP work on upper back and neck as required. Request GP or other appropriate healthcare professionals to conduct a physical examination. Please write your plan as Nurse Practitioner who works in primary care. One study found that the APSO order was better than the typical SOAP note order in terms of speed, task success (accuracy), and usability for physician users acquiring information needed for a typical chronic disease visit in primary care. Read now. Plan to meet with Julia and Mrs. Jones next week to review mx. SOAP notes for Stroke 11. Sensation intact to bilateral upper and lower extremities. For example, SI for suicidal ideation is a common Bilateral ear canals are free from drainage. That's why we've taken the time to collate some examples and SOAP note templates we think will help you to write more detailed and concise SOAP notes. No thrills or bruits are present. John's personal hygiene does not appear to be intact; he was unshaven and dressed in track pants and a hooded jumper which is unusual as he typically takes excellent care in his appearance. Has had coronary artery disease, 10 weeks s/p surgery. Here are 11 fun and interesting group self-care activities that will leave you feeling refreshed and re-energized. Temporal factor: Is the CC worse (or better) at a certain time of the day? SOAP notes for Dermatological conditions, Name: Sanjay WarAge: 64 YearsHeight: 6 Feet 2 InchesWeight: 95 Kg, I live alone and I am an occasional drinker but I do not smokeMy father as well as mother both had HypertensionCurrently, I am on the following medication for hypertension as well as painHydrochlorothiazide 25mgDoxazosin 2mgCarvedilol 12.5mgMucinex D 2 tabletNaproxen 220 mg andMetformin 500mg, Past Medication History (PMH) about 3 months ago,Blood Pressure: 160/85 mm HgHeart Rate- 76 bpmWeight-95 kgHeight.-62BMI: 26.8(overweight)Total Cholesterol- 171mg/dl, LDL- 99mg/dl, HDL- 40mg/dlTriglycerides- 158mg/dlSerum creatinine- 2.2 mg/dlBlood Glucose- 110mg/dlUric Acid- 6.7 mg/dl, Sanjays BP is not at goal, because he is diabetic his goal should be <130/80mmHG.Despite triple antihypertensive therapy, B.P is not optimal because of many factors including the use of Mucinex D(which contains pseudoephedrine), Naproxen(NSAID) & non-compliance with a low sodium dietACEIs or ARB as drugs of choice for Diabetes.The use of a non-selective beta blocker is not the best selection for COPDSanjay has BPH & is on Doxazosin, an alpha-blocker that seems to control his BPH symptoms as well.However, dizziness & headaches like side effects of Doxazosin can be minimize by take the dose at night, Discontinue guaifenesin/pseudoephedrine preparation(especially if no longer needed for cold symptoms) or give a product containing only guaifenesin next time.Discontinue Naproxen.Go for an alternative(eg. Healthy diet (Dash dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans I fat. efective BP medication titration. SOAP notes for Hypertension 2. Reports father died at the age of 95 years old 2 years. Family History: Mother died from congestive heart failure. It is primarily evident through a diagnosis of Major Depressive Disorder. Darleene has no history other than hypertension. After starting medications, the target blood pressure for patients younger than 65 years should be 140/90 for the first three months, followed by 130/80. Neurologic: Alert, CNII-XII grossly intact, oriented to person, place, and time. Constitutional: Vital signs: Temperature: 98.5 F, Pulse: 87, BP: 159/92 mm/hg, RR 20, PO2-98% on room air, Ht- 64, Wt 200 lb, BMI 25. SOAP notes for Depression 12. Fred reported 1/10 pain following treatment. The goal will be to decrease pain to a 0 and improve functionality. Provided client with education on posture when at the computer. Ruby's appearance and posture were different from what they were in our last session. at home and bloody nose x 3 days. These prompts will facilitate meaningful conversations between attending clients, helping to create a safe and comfortable environment. To meet with Bobby on a weekly basis for modalities, including moist heat packs, ultrasound, and therapeutic exercises.

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