Prepare mini-soap note on a patient


Assignment task: 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. 

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

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