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Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit as
Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit as a Word Document. See example template below for required format.
Review the rubric for more information on how your assignment will be graded.
Demographic Data
Patient initial (one initial only), age, and gender must be Health Insurance Portability and Accountability (HIPPA) compliant.
Subjective
Chief Complaint (CC)
History of Present Illness (HPI) (symptoms) in paragraph format
Past Medical History (PMH): Current problem-focused and document pertinent information only.
Current Medications:
Medication Allergies:
Social History: For current problem-focused and document only pertinent information only.
Family History: For current problem-focused and document only pertinent information only.
Review of Systems (ROS) as appropriate:
Objective
Vital signs
Mental Status Exam
Physical findings listed by body systems, not paragraph form.
Patient Health Questionnaires, Screenings, and the results (PHQ-9, GAD 7, suicidal)
Assessment (Diagnosis/ICD10 Code)
Include all diagnoses that apply to this visit.
Include one differential diagnosis.
Plan
Dx Plan (lab, x-ray)
Tx Plan: (meds)
Pt. Education, including specific medication teaching points.
Safety Plan
Referral/Follow-up
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