Submit 1 Mini-SOAP note on a patient that you saw in clinic this week.
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
*Based on population focus, some additional details may be required by faculty Top of Form
