Executive Solution Overview
. PLEASE CHECK ATTACHMENTS **files (3)** – ## NM701officevisitSOAPtemplate-11.docx – 27875.jpg – Full.m4a **## NM701officevisitSOAPtemplate-11.docx** **Date and time of simulation:** **Patient name:** **SUBJECTIVE** **CC (Chief Concern):** In patient’s own words **HPI:** (History of Present Issue) *…
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. PLEASE CHECK ATTACHMENTS
**files (3)**
– ## NM701officevisitSOAPtemplate-11.docx
– 27875.jpg
– Full.m4a
**## NM701officevisitSOAPtemplate-11.docx**
**Date and time of simulation:**
**Patient name:**
**SUBJECTIVE**
**CC (Chief Concern):** In patient’s own words
**HPI:** (History of Present Issue)
**\_\_\_** y/o G P (TPAL) reports
**(OLDCARTS)**
Other relevant information
**Current medications:**
**Allergies:**
**PMH: Past Medical history: (choose pertinent areas)**
· Medical:
· Surgical:
· Obstetric Hx:
·
GYN Hx:
·
Psychiatric Hx:
· Family history:
· Social history:
·
Health maintenance (PCP, immunizations, etc.)
**ROS: (choose pertinent systems)**
**OBJECTIVE**
· General Survey:
· Vital Signs: Wt, Ht, BMI, BP, HR, RR, Temp (as indicated)
· Targeted Physical Exam:
· In-office Diagnostics:
**ASSESSMENT** _(_ with ICD-10 codes
_)_
1. Episodic gyn problem= diagnosis (i.e. pelvic pain, contraceptive counseling, confirmation of pregnancy, etc.)
a. Include pertinent differentials
2. Chronic Health problems = diagnosis
**(optional)**
**PLAN: _(_** _Note that this Plan is not a Discharge Summary for the patient. Write it focusing on communication with the next clinician, not the patient.)_
**Treatment:**
· Medications & lifestyle changes:
· Diagnostic testing:
· Consultation/Coordination of care:
**Patient and family education:**(as appropriate)
**Follow up:**
·
RTC ___
**Signed:**
**27875.jpg**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/27875-jpg-10586679)
**Full.m4a**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/full-m4a-10586681)
**Full.m4a**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/full-m4a-10586681)
**## NM701officevisitSOAPtemplate-11.docx**
**Date and time of simulation:**
**Patient name:**
**SUBJECTIVE**
**CC (Chief Concern):** In patient’s own words
**HPI:** (History of Present Issue)
**\_\_\_** y/o G P (TPAL) reports
**(OLDCARTS)**
Other relevant information
**Current medications:**
**Allergies:**
**PMH: Past Medical history: (choose pertinent areas)**
· Medical:
· Surgical:
· Obstetric Hx:
·
GYN Hx:
·
Psychiatric Hx:
· Family history:
· Social history:
·
Health maintenance (PCP, immunizations, etc.)
**ROS: (choose pertinent systems)**
**OBJECTIVE**
· General Survey:
· Vital Signs: Wt, Ht, BMI, BP, HR, RR, Temp (as indicated)
· Targeted Physical Exam:
· In-office Diagnostics:
**ASSESSMENT** _(_ with ICD-10 codes
_)_
1. Episodic gyn problem= diagnosis (i.e. pelvic pain, contraceptive counseling, confirmation of pregnancy, etc.)
a. Include pertinent differentials
2. Chronic Health problems = diagnosis
**(optional)**
**PLAN: _(_** _Note that this Plan is not a Discharge Summary for the patient. Write it focusing on communication with the next clinician, not the patient.)_
**Treatment:**
· Medications & lifestyle changes:
· Diagnostic testing:
· Consultation/Coordination of care:
**Patient and family education:**(as appropriate)
**Follow up:**
·
RTC ___
**Signed:**
**27875.jpg**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/27875-jpg-10586679)
**Full.m4a**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/full-m4a-10586681)
**## NM701officevisitSOAPtemplate-11.docx**
**Date and time of simulation:**
**Patient name:**
**SUBJECTIVE**
**CC (Chief Concern):** In patient’s own words
**HPI:** (History of Present Issue)
**\_\_\_** y/o G P (TPAL) reports
**(OLDCARTS)**
Other relevant information
**Current medications:**
**Allergies:**
**PMH: Past Medical history: (choose pertinent areas)**
· Medical:
· Surgical:
· Obstetric Hx:
·
GYN Hx:
·
Psychiatric Hx:
· Family history:
· Social history:
·
Health maintenance (PCP, immunizations, etc.)
**ROS: (choose pertinent systems)**
**OBJECTIVE**
· General Survey:
· Vital Signs: Wt, Ht, BMI, BP, HR, RR, Temp (as indicated)
· Targeted Physical Exam:
· In-office Diagnostics:
**ASSESSMENT** _(_ with ICD-10 codes
_)_
1. Episodic gyn problem= diagnosis (i.e. pelvic pain, contraceptive counseling, confirmation of pregnancy, etc.)
a. Include pertinent differentials
2. Chronic Health problems = diagnosis
**(optional)**
**PLAN: _(_** _Note that this Plan is not a Discharge Summary for the patient. Write it focusing on communication with the next clinician, not the patient.)_
**Treatment:**
· Medications & lifestyle changes:
· Diagnostic testing:
· Consultation/Coordination of care:
**Patient and family education:**(as appropriate)
**Follow up:**
·
RTC ___
**Signed:**
**27875.jpg**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/27875-jpg-10586679)
**Full.m4a**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/full-m4a-10586681)
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