The intent of this book is to provide multiple formats of SOAP note contents for common clinical visits. The intent of this book is not to replace clinical information. Knowing that clinical guidance can change in accordance with the most recent evidence-based practice, I did not create this book as a medical reference. Rather, this book should be used as a guide to format SOAP note documentation, including tips to streamline the SOAP note writing process, primarily through the use of a custom working template.Inside:Tips to Streamline the Documentation Process, Keyboard Tips for Efficient Transcription, Using this Book to Create a Template, Clinical SOAP Note Format, Abbreviations in Notes, Referring to time within notes, Physical Exam Narrative, Full SOAP example. Sports Physical, Pediatric Well Visit NotesSupplemental Lab Result Notes: Sample Lab Sets to Order, Iron deficiency, Hypertriglycerides, Pediatric lipid screening, HyperlipidemiaSOAP Notes for Common Primary Care Visits:Gastrointestinal Complaints: Constipation SOAP, Diarrhea Note, Gastroenteritis Note, GERD Note, Hemorrhoid Note, Rectal Bleed SOAPDermatology Complaints: General Skin Assessment Guidelines, Cellulitis SOAP, Mole SOAP, Rash SOAP, Acne Education Note, Diaper Rash Note, Eczema Note, Keratosis Pilaris Education, Lice Note, Scabies Note, Tinea Ungium Infection Education, Imbedded Tick Education, Varicose Vein EducationFatigue and Sleep Health: SOAPs and Sample Blurbs: Fatigue SOAP, Insomnia/Difficulty Sleeping SOAP, OSA NoteFever and Viral Infections: Fever Note, Mononucleosis SOAP, URI SOAP, Influenza NoteHeadache & Migraine: Headache SOAP, Migraine SOAPHead, Ears, Nose & Throat: Acute Otitis Media SOAP, Acute Otitis Externa Note, Concussion Follow-Up Note, Conjunctivitis SOAP, Cerumen Impaction SOAP, Strep Pharyngitis SOAP, Bronchitis Education Note, Tonsil Stone Education NoteHypertension: Pre-hypertension Education, New Diagnosis of HTN SOAP, Hypertension follow-up SOAPJoint Health/Pain: Sample Blurbs: Carpal Tunnel Note, Gout Education, Raynaud Education, Rheumatoid/Autoimmune Workup Note, Chondromalacia/Runner’s Knee NoteLifestyle Modification & Weight Management: Weight loss education note, Obesity note, Bariatric Surgery Initial Visit SOAP, s/p Bariatric Surgery Follow-Up Note, Pre-Diabetes SOAP, Smoking Cessation SOAPMental Health: ADD/ADHD SOAP, ETOH/Alcohol Abuse & Misuse Note, Anxiety Note, Depression NoteOrthopedics & Musculoskeletal: Arthritis SOAP, Ankle pain SOAP, Back Pain Note, Hip Pain Note, De Quervain’s Tenosynovitis Education Note, Knee Pain Education, Myalgia Education, Neck Pain Education, SI Joint Note, Osteopenia Education, Sprain Education, Tennis Elbow Education, Shoulder Pain SOAP, TMJ NotePain Management: Acute Back Pain Note, Chronic Back Pain Note, Acute on Chronic Back Pain SOAP, Nonpharmacological Pain Management NoesPodiatry Sample Blurbs: Ingrain Toenail, Plantar Fasciitis, Plantar WartsSexual & Reproductive Health: Amenorrhea SOAP, Abnormal Uterine Bleeding Note, Bacterial Vaginitis Note, Dyspareunia Note, Pregnancy Note, Erectile Dysfunction Note, Genital Herpes Note, STI Exposure SOAP, UTI SOAP, Vaginal Discharge Note, Yeast Infection NoteGeneral Contraceptive Notes, Oral contraceptives, IUD, Nexplanon, Patch, RingSexual Health Screening Notes: Breast Cancer Screening Note &STI Screening NoteProcedure Notes, to include Incision & Drainage Procedure, Nexplanon Insertion, Shave Biopsy, Steroid Injection Procedure, PAP Smear, and Wart Destruction Procedure
✔ Author(s): Lena Empyema
✔ Title: SOAP Note Examples & Documentation Tips: For Nurse Practitioners in Primary Care
✔ Rating : 4.1 out of 5 base on (190 reviews)
✔ ISBN-10: B096TMJ1WJ
✔ ISBN-13: 978B096TMJ1W8
✔ Language: English
✔ Format ebook: PDF, EPUB, Kindle, Audio, HTML and MOBI
✔ Device compatibles: Android, iOS, PC and Amazon Kindle
Readers' opinions about SOAP Note Examples & Documentation Tips by Lena Empyema
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The world-building in this book was simply phenomenal. I was transported to a different realm and felt like I was part of the characters' journey. The attention to detail made it all so immersive.
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I loved the powerful messages hidden within the story. The book tackled important social issues and made me ponder the world we live in. It's a must-read for everyone.
