Neuro Soap Note
Create a neuro-related CC. Create an ID, CC, HPI, ROS, V/S, physical findings, and assessment with at least 3 differential diagnoses, a final diagnosis, and treatment plan in a full SOAP note format. Use a neuro related CC that a patient would present with in a primary care setting (i.e. no emergency room or ICU type complaints). Examples: regular headaches, migraines, dizziness, dementia or memory loss, weakness, neuropathy, etc..
diagnostic and treatment plan
Include at least two references for your diagnostic and treatment plan. They should be recent (in the last 5-10 years) and peer-reviewed. Use APA title page, citation, and references. Ensure the treatment plan includes all components (diagnostic plan, therapeutic plan, education plan, and follow up).
The ROS and physical exam in your document should be written up as they would be for a problem focused visit. The neurological part of the physical exam write up should be a comprehensive write up, including everything you assessed in your recording.
(Important information) when writing the History of present illness HPI) use this OLDCARTs Onset, Location, Duration, Characteristics, Aggravating facting, Relieving factor and Treatment and severity