Soap Note for type II diabetes mellitus
SOAP NOTE SAMPLE FORMAT FOR MRC
| Name: | Date: | Time: |
| Age: | Sex: | |
| SUBJECTIVE | ||
| CC:
“ .”
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| HPI:
.
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| Current Medications:
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| PMHx:
Allergies:
Medication Intolerances: Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
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| Family History
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| Social History
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| ROS | ||
| General | Cardiovascular
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| Skin
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Respiratory
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| Eyes
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Gastrointestinal
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| Ears
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Genitourinary/Gynecological
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| Nose/Mouth/Throat
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| Breast
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Neurological
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| Heme/Lymph/Endo
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Psychiatric
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| OBJECTIVE | ||
| Weight lb | Temp – | BP |
| Height 5’1 | Pulse | Respiration |
| General Appearance
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| Skin
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| HEENT
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| Cardiovascular
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| Respiratory
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| Gastrointestinal
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| Genitourinary
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| Musculoskeletal
Full ROM seen in all 4 extremities as patient moved about the exam room. |
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| Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait normal. |
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| Psychiatric
Alert and oriented. Dressed in clean clothes. Maintains eye contact. Answers questions appropriately. |
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| Lab Tests
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| Special Tests- No ordered at this time.
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| Diagnosis | ||
| Differential Diagnoses
Diagnosis
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| Plan/Therapeutics | ||
| · Plan:
· Medication – · Education – · Follow-up –
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References
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