SOAP note

Discussion Question: Develop a SOAP note for a patient you encountered who had an abnormal laboratory assessment test. Explain the meaning of the laboratory diagnostic and its impact on the treatment plan.

70 yrs old male, hispanic, for F/ u on recent lab results done
CBC result normal results in the normal range, no anemia, HgA1c 6.8, out of range, the trend is the same from last year lab reports. lipid profile normal, VS today BP 119/79, HR 68, RR 17, O 2 sat 93% on Ra. pain 0/10. He C/O pain bilat knees as chronic complain. last time he was seen by Orthopedic MD was about 2 yrs ago per pt and wife. pt under the care of Nephrologist Dr. XX on 6/21/21 . pt and wife state they will call when need to refill RX.

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