Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit as a Word Document. See example template below for required format.
32 y/o female G4P2 presents to clinic at 10 weeks gestation. please fill in the rest with relevant information.
Review the rubric for more information on how your assignment will be graded.
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
Health maintenance (including when screenings, immunizations, etc., are next due):
______________________
Writing Guide:
Demographic Data
32 year old female
Subjective
Chief Complaint: Routine prenatal care visit at 10 weeks gestation
History of Present Illness: Patient presents for her initial prenatal care appointment. She reports her last menstrual period began on November 15th and she experienced normal menstrual cycles of 28 days prior to conception. She has experienced mild nausea and fatigue but no vomiting.
Past Medical History: Unremarkable
Family History: Mother with gestational diabetes
Social History: Married, lives with husband. Smokes half a pack of cigarettes daily. Works as an accountant.
Review of Systems: Negative except for nausea and fatigue as noted in HPI
Objective
Vital Signs: BP 110/70, Pulse 80, Temp 98.6 F
Physical Exam: Fundal height measures 10 weeks. Fetal heartbeat detected via Doppler at 140 bpm. Breast exam normal. Neurological and cardiovascular exams unremarkable.
Assessment
ICD-10: O09.00, Normal pregnancy, 10 weeks
Plan
Diagnostic Plan: Order prenatal panel labs, schedule anatomy ultrasound for 18-20 weeks
Treatment Plan: Start prenatal vitamins, discuss smoking cessation counseling/resources
Patient Education: Review early pregnancy symptoms, discuss importance of folic acid, discuss smoking risks and goal to quit, schedule next prenatal visit
Referrals/Follow Up: Schedule next prenatal visit in 4 weeks. Refer to smoking cessation program.
Health Maintenance: Schedule Pap smear, discuss breast self exams
