Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit here as a Word Document. See the example template below for the required format.
Review the rubric for more information on how your assignment will be graded.
63 y/o male with BHP, presents to the clinic for 1 year follow up and refill medication.
Problem-Focused SOAP Note Format
Demographic Data
- Age, and gender (must be HIPAA compliant)
Subjective
- Chief Complaint (CC) unless an Annual Physical Exam (APE)
- 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/ICD10 Code)
- Include all diagnoses that apply for this visit
Plan
- Dx Plan (lab, x-ray)
- Tx Plan: (meds)
- Pt. Education, including specific medication teaching points
- Referral/Follow-up
- Health maintenance (including when screenings, immunizations, etc., are next due):
