Submit a full SOAP note using provided bellow template. Presumptive Dx related to a female or male diagnosis. Remember to include a thorough GYN/GU history. Use attached SOAP Note template which is in the WORD format. Review the video on how to write a SOAP Note and use the perfect soap note document to guide you.
Remember to always document the education about when to seek ER care.
In the evaluation of the encounter also include your level of interaction with the patient.
Remember to also include the reason why the patient is taking each one of the listed medicines.
Try including the ages of the listed family members.
Remember to include rationales with each one of the differential diagnosis. (short explanation about why each of those diagnoses were considered).
You must include 3 differential diagnosis plus the actual diagnosis.
On the plan, schedule a follow up appointment.
On the evaluation of the patient encounter please mention what was your participation for this case, list your strengths, weaknesses and reflect on what was learned with this case.