SOAP Note:
The student documents a targeted subjective assessment, including HPI. The student includes information that is provided in the case including pertinent past medical, surgical, and social history, and relevant review of systems if applicable.
SOAP Note: Objective History
The student documents a relevant objective assessment in the mental status exam.
SOAP Note: Assessment/Differential Diagnosis
The student identifies the most likely diagnosis or diagnoses associated with the information provided in the case.
SOAP Note – Plan
The student suggests a plan of care that includes appropriate additional workup, pharmacologic and/or nonpharmacologic treatments, patient education, and follow-up.
The student provides a 1-2 paragraph overview of their learning from the case, errors that they made, and strategies for improving performance on future cases.
