Soap note UTI

/in /by

Follow these guidelines for APA. This is maternity note ,please adapt to advance primary care 

References in APA have to be within a 5-year range.

Make sure you include Psych History as well and also Genitourinary system.

 

Patient Demographics

Age:

24 years

Race:

Hispanic

Gender:

Male

Insurance:

No insurance

Referral:

No referral

Clinical Information

Time with Patient:

30 minutes

Consult with Preceptor:

20 minutesType of Decision-Making:Low complexityReason for Visit:EpisodicChief Complaint:DysuriaType of HP:DetailedSocial Problems Addressed:Sanitation/Hygiene
Safety
Sexuality
Prevention
Procedures/Skills (Observed/Assisted/Performed)

Physical Assessment – Physical Assessment (Perf)
General Skills – Urine Analysis via dipstick (Perf)
General Skills – Vital Signs (Perf)
ICD-10 Diagnosis Codes#1 – N39.0 – URINARY TRACT INFECTION, SITE NOT SPECIFIED

Medications

# OTC Drugs taken regularly:

0# Prescriptions currently prescribed:0# New/Refilled Prescriptions This Visit:2Types of New/Refilled Prescriptions This Visit:
Infectious Diseases – Fluoroquinolones
Infectious Diseases – Urinary anti-infectives

Other Questions About This Case

Patient’s Primary Language:SpanishSmoking Assessment:Current SmokerAdvanced Directive:No

Packs per day:

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