Submit 1 mini-SOAP note on a patient that you saw in clinic this week. Submit here as a Word Document. See example template below.
Demographic Data
Patient initial G (one initial only), age 12, and gender Female must be HIPAA compliant Diagnosis: (reason for visit) Annual check up and vaccination for school
Subjective
Chief Complaint (CC)
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/ICD 10 Code)
Include all diagnoses that apply for this visit
Plan
Dx Plan (lab, x-ray) if applicable
Tx Plan: (meds) IF applicable
Pt. Education, including specific medication teaching points
Referral/Follow-up
Health maintenance (including when screenings, immunizations, etc., are next due):
*based on population focus, some additional details may be required by faculty
