Submit 1 Mini-SOAP note on a patient that you saw in clinic this week.

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