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Write a a full SOAP Note about HEENT – head, eyes, ears, nose, and throat.
Chief complaint :”I have had sore throat for 2 days”
Requirements:
1. The Subjective section includes the following: ID (Initials, Age, DOB, Sex, Race, Accompanied, and Historian), CC, HPI (using OLDCARTS for problem-focused history), PMH, Family History (as pertinent), Social History (as pertinent), and ROS (problem-focused based on body system).
2. The Objective section includes: expected vital signs and the physical examination documentation with detailed focus on the week’s body system (as well as general, and basic assessment of CV and Pulmonary).
3. The Assessment section must contain 3 differential diagnoses with rationale and in-text citations to credit the evidence-based sources used to defend the diagnosis choices. One of these three diagnoses must be the final or working diagnosis.
4. The Plan section is based on the working/ final diagnosis. This must include the five aspects of a plan which are diagnostics, treatments, education, referral (if applicable), and follow-up. The student should use in-text citations to credit their sources of information for each aspect of the plan.
5. The student must use a minimum of two references which should be recent (within last 5, but up to 10 years if clinical practice guideline) and should be peer-reviewed.
6. Use APA title page, citations, and reference format.
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