Patient is a 15 year old female coming in because she has been having pain while she pees
-Patient is a 15 year old female coming in because she has been having pain while she pees.
-She has no known allergy to meds or anything else.
-Mom has asthma
-Dad does not have any medical history.
-Sister also has asthma
-Brother does not have any medical history.
SOAP NOTE TEMPLATE
Review the Rubric for more Guidance
Demographics
Chief Complaint (Reason for seeking health care)
History of Present Illness (HPI)
Allergies
Review of Systems (ROS)
General:
HEENT:
Neck:
Lungs:
Cardio
Breast:
GI:
M/F genital:
GU:
Neuro
Musculo:
Activity:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
Vital Signs
Labs
Medications
Past Medical History
Past Surgical History
Family History
Social History
Health Maintenance/ Screenings
Physical Examination
General:
HEENT:
Neck:
Lungs:
Cardio
Breast:
GI:
M/F genital:
GU:
Neuro
Musculo:
Activity:
Psychosocial:
Derm:
Diagnosis
Differential Diagnosis
ICD 10 Coding
Pharmacologic treatment plan
Diagnostic/Lab Testing
Education
Anticipatory Guidance
Follow up plan
Prescription
See Below (scroll down)
References
Grammar
EA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)______________________________ Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________ Refill: _________________
No Substitution
Signature:____________________________________________________________
Signature (with appropriate credentials):_____________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
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