SOAP for Family Medicine

Description:

Offering step-by-step guidance on how to properly document patient care, this updated Second Edition presents 90 of the most common clinical problems encountered on the wards and clinics in an easy-to-read, two-page layout using the familiar "SOAP" note format. Emphasizing the patient’s clinical problem, not the diagnosis, this pocket-sized quick reference teaches both clinical reasoning and documentation skills and is ideal for use by medical students, Pas, and NPs during the Family Medicine rotation.

Table of Contents:

Normal Lab Values

How To Write A Soap Note

I. MEDICINE

1. Adult History & Physical, Preventive Maintenance

2. Allergic Rhinitis

3. Anemia, Iron-Deficiency

4. Appendicitis

5. Asthma

6. Bronchitis/Pneumonia

7. Chest Pain

8. Cholelithiasis/Cholecystitis

9. Conjunctivitis

10. Constipation

11. Delirium/Dementia

12. Diabetes Mellitus

13. Dizziness

14. Epididymitis/Prostatitis

15. Fibromyalgia

16. Gastritis/Gastroesophageal Reflux/Peptic Ulcer Disease

17. Gastrointestinal Bleed

18. Headache

19. Hyperlipidemia

20. Hypertension

21. Hyperthyroidism

22. Hypothyroidism

23. Nephrolithiasis

24. Obesity

25. Osteoarthritis

26. Pharyngitis/Tonsillitis

27. Sinusitis

28. Urinary Incontinence

29. Urinary Tract Infection

II. OBSTETRICS & GYNECOLOGY

30. Well Woman Exam, Preventive Maintenance

31. First Trimester Visit

32. Second Trimester Visit

33. Third Trimester Visit

34. Amenorrhea

35. Bleeding During Pregnancy

36. Abnormal Uterine Bleeding

37. Dysmenorrhea/Pelvic Pain

38. Family Planning

39. Infertility

40. Mastalgia

41. Menopause

42. Pelvic Inflammatory Disease

43. Postpartum Visit

44. Premenstrual Syndrome/Dysphoric Disorder

45. Sexually Transmitted Infections

III. PEDIATRICS

46. Newborn Exam

47. Well Child Exam (2–12 Months)

48. Well Child Exam (13–24 Months)

49. Well Child Exam (25 Months-Preadolescence)

50. Well Child Exam (Adolescence)

51. Abdominal Pain

52. Acute Gastroenteritis

53. Acute Otitis Media/Otitis Externa

54. Attention-Deficit/Hyperactivity Disorder

55. Fever

56. Heart Murmurs

57. Nocturnal Enuresis

58. Rash/Viral Exanthems

59. Respiratory Infection

60. Urinary Tract Infection

IV. DERMATOLOGY

61. Acne

62. Atopic Dermatitis

63. Basal Cell Carcinoma

64. Bites (Animal/Human)

65. Burns

66. Cellulitis

67. Lyme Disease

68. Melanoma

69. Molluscum Contagiosum/Verruca

70. Psoriasis

71. Scabies

72. Squamous Cell Carcinoma/Actinic Keratosis

73. Tinea

74. Urticaria

V. ORTHOPEDIC CONDITIONS

75. Sports Medicine Screening Exam

76. Ankle/Foot Pain

77. Back Pain

78. Elbow Pain

79. Knee Pain

80. Neck Pain

81. Shoulder Pain

82. Wrist/Hand Pain

VI. PSYCHIATRY/PSYCHOSOCIAL ISSUES

83. Alcoholism

84. Anxiety/Panic Attacks

85. Bipolar Disorder

86. Child Abuse

87. Depression

88. Domestic Violence

89. Drug Abuse

90. Elder Abuse

Index