W6 Mini soap note

chief complaint – I always have this urge to pee and when I do it burns

Diagnosis – Urinary tract infection

make up the rest of the information! Must have medical history and meds please make it up.

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Demographic Data

Age, and gender (must be HIPAA compliant)

Subjective

• Chief Complaint (CC) unless an Annual Physical Exam (APE)

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/ICD10 Code)

Include all diagnoses that apply for this visit

Plan

• Dx Plan (lab, x-ray)

Tx Plan: (meds)

• Pt. Education, including specific medication teaching points

Referral/Follow-up