soap note a soap note consists of the following elements 1 subjective information information obtained from the patient or the patient s family or significant others information including perception of ...
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...Soap note a consists of the following elements subjective information obtained from patient or s family significant others including perception his her nutritional status appetite food intake dietary habits preferences allergies and intolerance diarrhea nausea vomiting constipation recent weight loss gain activity level socio economical psychological cultural ability disability such as vision chewing problems in elderly eg pt stated reported claimed said to have poor c o x since yesterday evening states that she has lost kg last months was on kcal wt reduction plan not it properly diet hx reflects an imbalanced day with sweetened beverages exercises regularly week objective factual relevant problem can be confirmed by physical finding observation lab results other parameters anthropometric measurements age ht frame size ibw adj tsf mac mamc body ubw for pediatrics head circumference diagnosis blood pressure glucose levels order physician medications disease condition drug nutrient inte...