Although you will be creating a SOAP note with an ID, CC, HPI, and ROS, please only record the HEENT system in the video. Do not record any other questions or patient teaching.
Ensure that you and the patient are in the camera’s frame at all times. This may involve moving the camera as needed to ensure the instructor can view and grade the exam
There is no video editing permitted, and you may not stop and restart the filming, as doing so gives students the advantage of looking at notes and instructions. The exam is meant to be performed from beginning to end without pausing.
For your note this week, create an HEENT related CC. Create an ID, CC, HPI, ROS, V/S, physical findings, and assessment with at least 3 differential diagnoses, a final diagnosis, and treatment plan in a full SOAP note format. Use an HEENT related CC that a patient would present with in a primary care setting (i.e. no emergency room or ICU type complaints. Examples: sore throat, ear ache, hearing loss, eye drainage, etc.).
Include at least two references for your diagnostic and treatment plan. They should be recent (in the last 5-10 years) and peer-reviewed. Use APA title page, citations, and reference format. Ensure the treatment plan includes all components (diagnostic plan, therapeutic plan, education plan, and follow up).
The ROS and physical exam in your document should be written up as they would be for a problem focused visit. The HEENT part of the physical exam write up should be a comprehensive write up
