Patient: 26 year-old female came into the office for her yearly physical with a diagnosis of cystitis ******Please use OLDCARTS?for the history of the present illness***** answer

SOAP NOTE TEMPLATE (Well Exam/Comprehensive Visit)

Student Name: Date: Course:

Patient Demographics: (age, gender, ethnicity, etc.)

Chief Complaint: “quote patient”

History of Present illness: 7 attributes required

______________________________________________________________________________

(For patients who are Newborns, Infants, Toddlers, or School Age)

Birth History:

Nutrition:

Elimination:

Activity:

Sleep:

Safety:

Developmental Milestones:

(For patients who are Adolescents)

HEADSSS Assessment: BRIEFLY summarize your assessment here and elaborate on any abnormal findings

______________________________________________________________________________

Past Childhood Illnesses: measles, mumps, rubella, varicella, scarlet fever, rheumatic fever, polio, and any other childhood illnesses such as Asthma

PMH: dates in reverse chronological order.

PSH: surgery dates in reverse chronological order.

Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies

Untoward Medication Reactions: include type of reaction/severity/date

Immunization Status: e.g. Flu, Prevnar 13, TdaP, etc. Date must be included

Screenings: e.g. Newborn screening, vision screening, dental visits, TB screening/PPD, etc… (Indicate if results were normal or abnormal)

FMH: include relevant genetic risk history for living/deceased immediate relatives including grandparents, parents, siblings, children, grandchildren; for deceased relatives include cause of death and age; for sick relatives include age of onset

Personal History/Social History: family relationship status, children, occupation, living arrangements, exercise, personal interests, religion, illicit drug use, tobacco-use in pack years, if stopped smoking for how long did they smoke and when did they quit smoking; alcohol use—how many drinks/week, type of alcohol

Females: LMP and relevant OB/GYN history Gravida, Para, Abortions-spontaneous vs. induced

age of menarche, duration of period, avg. length of cycles, flow, etc.

Sexual History: #of partners, sex of partner/s, protected/unprotected sexual relations, contraception

Current Medications/OTCs/Supplements: indicate Dose, Route, Frequency (write class of medication in parentheses):

For Comprehensive Visit, document a full ROS/PE

Review of Systems:

General:

Skin:

HEENT:

Head:

Eyes:

Ears:

Nose:

Throat:

Breasts:

Respiratory:

Cardiovascular:

Gastrointestinal:

Genitourinary:

Peripheral Vascular:

Musculoskeletal:

Neurologic:

Hematologic:

Lymphatic:

Endocrine:

Psychiatric:

Screening Tool: ONE screening tool is required and it should be scored (e.g. PHQ-2 Depression Scale, CRAFFT, etc.)—if screening is positive list as a diagnosis with a plan.

Physical Exam:

Vital Signs: Blood Pressure- __ P- __ RR- __ T- __ Pain- __ Height- __ ( %tile) Weight- __ ( %tile)

BMI (>2 yrs) – __ ( %tile)

Head circumference – (if applicable)

General:

Skin:

HEENT:

Head:

Eyes:

Ears:

Nose:

Throat:

Neck:

Breasts:

Lungs:

Heart:

Abdomen:

Genitourinary:

Rectal:

Peripheral Vascular:

Lymphatic:

Extremities: Musculoskeletal:

Neurological:

Pertinent Labs/Diagnostic Testing: Indicate any previous labs or diagnostics done that are relevant to today’s visit, as well as any Point of Care Testing (POCT) done during the visit with results.

Differential Diagnosis Diagnostic Reasoning Exercise:

(Please complete this differential diagnosis section if there are any chief complaints/symptoms and/or new abnormal findings during the physical exam)

Minimum of 3 differential diagnoses/maximum of 5 differentials—the table will help with the narrative write-up required below the table.

Differential Diagnoses	Pathophysiology (include APA citations)	Pertinent Positives	Pertinent Negatives
1.
2.
3.
4.
5.

In a narrative format explain how you arrived at your final diagnosis or working diagnoses based on the CC/HPI, PMH, PSH, ROS, & Physical Exam (pertinent +/– will guide this process). This should be written using examples of how the history/clinical presentation led to the final diagnosis or working diagnosis (APA citations to your references must be included – use resources with Evidence Based Guidelines)

Assessment/Plan:

Include a brief summary of the visit here

(APA citations required in your plan)

**New Diagnosis: If you have not made a diagnosis, then you would use the ICD-10 code for the symptomatology since r/o diagnoses are not billable. This should be followed by a plan of care that is evidenced based.

1. Diagnosis # 1 ICD-10 (Well exam diagnosis code according to age of the patient)

a. Plan listed here (plan should be evidenced based, if not, state why the plan deviated from the evidence)

b.

c.

2. Diagnosis # 2 ICD-10 may be related to CC/HPI, abnormal finding on exam, OR a chronic condition which is being followed-up (e.g. asthma, SSA, diabetes, etc.)

a. Plan listed here

b.

c.

3. Diagnosis # 3 ICD-10 may be counseling (eg. dietary, smoking cessation, etc.) or vaccinations administered

a. Plan listed here

b.

c.

Health Maintenance: Required App for USPSTF screening guidelines https://epss.ahrq.gov/PDA/index.jsp

Must list all screenings/lifestyle recommendations that are age appropriate (e.g. seasonal flu vaccine, HIV screening; STI screenings, obesity—nutritional/exercise counseling; smoker—tobacco cessation program, etc.)

RTC: (Document disposition)

References (APA Format)

FACULTY ONLY

Grade __________

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