Mini-SOAP note

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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. Review the rubric for more information on how your assignment will be graded. 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

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