|Sources / references||4|
|Description / paper instructions
This paper is to follow the format for the discussion of an establish patient, 35y/o complaining of headaches in the last month and two sporadic blood pressure checks at the pharmacy that were high, family history of hypertension and strokes. You can elaborate on this case.
SOAP FORMAT & RUBRIC
Initials of Patient:
SUBJECTIVE DATA (30 points); GRADE RECEIVED: _____
Past history (include dates):
Family History: Alive, Deceased, Age, Diseases, Health Conditions that place patient at risk (ages)
Determine Which LEVEL of HISTORY (Choose one):
OBJECTIVE DATA (30 points) Grade received_____
Determine Billing LEVEL OF PHYSICAL OBJECTIVE EXAM (choose one):
Laboratory Data Already Ordered and Available for Review (If not done will go in plan):
Diagnostic Procedures/Data Already Ordered and Available for Review (If not done will go in plan):
ASSESSMENT (15 points) GRADE RECEIVED____
3) Differential Diagnoses for top diagnoses
4) Identify Risk Factors
PLAN (15 points) GRADE RECEIVED________
For Each Diagnosis or Health Problem Identified as Appropriate:
For the Encounter Final Level of Decision Making: (give rationale for level which is based on Hx, physical, Decision making); Choose one
Billing Level: Give the reason for the Billing by E and Coding as per Number of Systems Reviewed and Level of Physical Exam.
Write 1-2 paragraph summary listing the subjective and objective data that supports your main diagnosis.
GENERAL FORMAT REQUIREMENTS:
2. Use of APA style of references in reference list