ESTHER PARK ABDOMINAL PAIN SOAP NOTE

ESTHER PARK ABDOMINAL PAIN SOAP NOTESOAP Note Greeting S:  CC: “I have pain/swelling/itching in my leg/ear/etc….” o EMPATHY!!!!!!  HPI: o Onset: o Location: o Duration: o Characteristics/description: o Aggravating factors: o Relieving factors: o Treatment: o Current pain/pain at its worst (pain scale) o EDUCATION!!!!  Current Meds: o What? o Why? o Dose o Frequency o Started when? o Last time taken o Help the diagnosis? o Any vitamins? o Supplements? o Herbs? o EDUCATION!!!!! And “Thank you for telling me about your meds…”  Allergies: o Meds o Environmental o Latex o What happens? o When discovered? o How treated? o Hives, eczema o  PMH: o When dx’d? o How managed? o Last “flare-up/episode” o Describe symptoms o Hospitalizations o Triggers/aggravating factors o Sx o EDUCATION/EMPATHY!!!! ESPECIALLY WITH T2DM/BLOOD SUGAR CHECKS, ETC. And “Thank you for telling me about your history…”  Social Hx: o Education level o Living situation o Stressors/current stress level o Activity level  Regular exercise o Occupation  Hrs worked o Diet/nutrition  Last mea