“Assessment and Management of Headache in a 45-Year-Old Hispanic Female without Insurance: A SOAP Note Analysis”

SOAP note headache 
Age:45 years
Biological Sex:Female
Race:hispanic
IInsurance:NO INSURANCE
Referral:
No referral
Clinical Information
Time with Patient:30 minutes
Type of Decision-Making: Moderate complexity
Reason for Visit:Other
Chief Complaint: headache
Type of HP: Problem Focused
Social Problems Addressed:
ICD-10 Diagnosis Codes
#1 – R51.9 – HEADACHE, UNSPECIFIED
Medications
# OTC Drugs taken regularly:1
# Prescriptions currently prescribed:0
# New/Refilled Prescriptions This Visit: 0
Other Questions About This Case
Patient’s Primary Language:Spanish
Smoking Assessment: Never
APA 7th edition style, two academics references no longer than 5 years published.