Make a SOAP Note
Create an HEENT related CC. Create an ID, CC, HPI, ROS, V/S, physical findings, and assessment with at least 3 differential diagnoses, a final diagnosis, and treatment plan in a full SOAP note format. Use an HEENT related CC that a patient would present with in a primary care setting (i.e. no emergency room or ICU type complaints. Examples: sore throat, ear ache, hearing loss, eye drainage, etc.).
· Include at least two references for your diagnostic and treatment plan. They should be recent (in the last 5-10 years) and peer reviewed. Use APA title page, citations, and reference format. Ensure the treatment plan includes all components (diagnostic plan, therapeutic plan, education plan, and follow up).
· The ROS and physical exam in your document should be written up as they would be for a problem focused visit.
SOAP NOTE TEMPLATE
Subjective
ID: Include info such as initials, DOB and age, race, gender, whether the patient is a reliable source, and how they came to the clinic (alone/ accompanied by spouse, etc.) Some clinicians write a statement about their overall reliability as a historian/recorder of their information. To protect confidentiality, please use a made up DOB and initials.
CC: ALWAYS in patient’s own words. Use quotations.
HPI Write this out in Paragraph form , not bullets. Include all the elements of HPI.
“OLDCARTS”
Onset/timing
Location
Duration
Context/Setting & Characteristics (i.e. Quality)
Aggravating factors and Associated Symptoms
Relieving factors
Treatments tried/Modifying Factors
Severity
VS: Temp, BP, RR, HR
Example:
HPI : Jillian X, a 63 year old white Jewish female, is here for her annual wellness visit. She states that she is in overall average physical health and her last physical was mo/d/2018. Her last mammogram was x/xx/20xx and last pap smear was x/xx/20xx, both normal. Jillian has had most normal health screenings as advised, and her last cholesterol levels were done on x/x/20xx and normal. She admits she has never had a colonoscopy. Her current complaint list includes a runny nose and ear pain that began 3 weeks ago (8/19/2019) and occurs intermittently. She has used aloe vera homemade remedy and feels relieved from her remedy within in 20 min. The symptoms were not so severe as to cause her to seek treatment (those she report ear ache as 8-9/10) but she felt she was able to handle them at home. She has no other complaints at this time.
PMH
Medical Problem list:(diabetes, asthma, HTN, etc)
Surgeries and hospitalizations (include mo/year ):
Immunizations: (including annual flu vaccine, for older people PNA and shingles vaccine)
Allergies: (food, drug, environmental, and the reaction)
Medications (Rx and OTC, supplements and herbal)
Family History (use abbreviations – MGM, FGM, FGF, etc. ask about siblings and children. Include ages of parents and relatives at the age they passed away)
Chemicals: (including ETOH, tobacco/nicotine, drugs)
Diet/exercise/caffeine (general diet – vegetarian? Red meat? Fast food and how often), exercise- what form, how long and often)
Sexual/Reproductive History LMP, contraception and protection, birth history (can also go up in PMH/surgeries if c-section), STI history, partners, orientation)
Social History :
Occupation,marital/relationship/military status & current living situation: THis should be obvious. For living situation, make sure to include whether house, apartment, hotel, shelter, etc.
Spiritual/Social Supports: (indicate religious affiliation if they have one, major belief systems, community or other social support)
Safety: Helmets, seatbelts, texting/drinking and driving, does the patient own guns? Keep them locked? Own a pool on property? Any history of domestic violence/partner violence?
ADLs/IADLs/AADLs: (for geriatrics or adults with disabilities)
Review of Systems (these are the official 14 systems used for Evaluation and Management Services (EMS) recognized by DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services). These are usually listed as negatives and positives after each system heading, but some providers write it out as a paragraph. Samples of things you can write here are found in Bates’ guide to Physical Assessment and History Taking, on page 12 and 13.
· Constitutional
· Eyes
· Ears, Nose, Throat
· Cardiovascular
· Respiratory
· Gastrointestinal
· Genitourinary
· Musculoskeletal
· Integumentary/Breast
· Neurologic
· Psychiatric
· Hematologic/Lymphatic
· Endocrine
· Allergic/Immunologic
Objective
