Assignment task:
Create SOAP Note using the following presenting issue:
A 24-year-old woman and her husband arrive for a consultation with the general practitioner. They have been trying to conceive for a year but have not been successful.
Requirements:
Incorporate at least 12 medical terminologies, all terms must be specific to the presenting issue. it should have 3 terms in each section
Identify the 10 medical terminologies in bold text (e.g, biopsy, cardiology, etc..)
*Medical terminologies should have a prefix, root/combining form and suffix*
The format of your note needs to include the 4 "SOAP" notes sections
Subjective - needs to have experiences, personal views or feelings of a patient or someone close to them. Sections include chief complaint, HPI ("OLDCARTS"), history, ROS, and medication history.
Objective - needs to include patient's encounter including information such as: vital signs, physical exam findings, laboratory data, imaging results, other diagnostic data, and recognition and review of the documentation of other clinician.
Assessment - must include patient's status through analysis of the problem, possible interaction of the problems, and changes in the status of the problems
Plan - the Information must include details such as the need for additional testing, consultation with other clinicians to address the patient's illnesses, and instructions provided to the patient. It also addresses any additional steps needed to treat the patient.