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
*Based on population focus, some additional details may be required by faculty Top of Form
