Submit 1 mini-SOAP note on a patient that you saw in clinic this week. Submit here as a Word Document. See example template below.
Demographic Data
Patient initial G (one initial only), age 12, and gender Female must be HIPAA compliant Diagnosis: (reason for visit) Annual check up and vaccination for school
Subjective
Chief Complaint (CC)
History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)
Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance as applicable
Family Hx: As applicable
Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
Objective
Vital signs
Physical findings listed by body systems, not paragraph form
Assessment (Diagnosis/ICD 10 Code)
Include all diagnoses that apply for this visit
Plan
Dx Plan (lab, x-ray) if applicable
Tx Plan: (meds) IF applicable
Pt. Education, including specific medication teaching points
Referral/Follow-up
Health maintenance (including when screenings, immunizations, etc., are next due):
*based on population focus, some additional details may be required by faculty
I hope I can get this same writer to complete the rough draft and final powerpoint as soon as the teacher posts her instructions. This part was great! Thank you so much.
James Raphael
This is exactly what I needed and the confidence that I am heading in the right direction to finish the assignment. Thank you so much.
Idalia Michael
