Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit here as a Word Document. See the example template below for the required format.<\/p>\n
Patient seen is a 53 y\/o female complaining of burning sensation while urinating.<\/p>\n
Dx: UTI<\/p>\n
please complete the mini SOAP below.<\/p>\n
Problem-Focused SOAP Note Format<\/p>\n
Demographic Data<\/p>\n
Age, and gender (must be HIPAA compliant)
\nSubjective<\/p>\n
Chief Complaint (CC) unless an Annual Physical Exam (APE)
\nHistory of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating\/Alleviating Factors, Relieving Factors, Treatment)
\nPast Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance as applicable
\nFamily Hx: As applicable
\nSocial Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
\nReview of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
\nObjective<\/p>\n
Vital signs
\nPhysical findings listed by body systems, not paragraph form
\nAssessment (Diagnosis\/ICD10 Code)<\/p>\n
Include all diagnoses that apply for this visit
\nPlan<\/p>\n
Dx Plan (lab, x-ray)
\nTx Plan: (meds)
\nPt. Education, including specific medication teaching points
\nReferral\/Follow-up
\nHealth maintenance (including when screenings, immunizations, etc., are next due):<\/p>\n
A mini-SOAP note for the 53-year-old female patient complaining of burning sensation while urinating:
\nDemographic Data:
\n53-year-old female
\nSubjective:
\nChief Complaint (CC): Burning sensation while urinating
\nHistory of Present Illness (HPI): Patient reports experiencing burning pain with urination for the past 2 days. The burning is constant and worsens with urination. She denies any other symptoms.
\nPast Medical History (PMH): Hypertension, diabetes
\nFamily History (FH): Mother with history of breast cancer
\nSocial History (SH): Married, retired teacher. Does not smoke or drink.
\nObjective:
\nVital Signs: Temp 98.6 F, BP 140\/90, Pulse 80, Respirations 18<\/p>\n
Physical Exam: General exam unremarkable. Abdomen soft, non-tender. Normal female genitalia on exam.
\nAssessment:
\nUrinary tract infection (UTI) (N39.0)
\nPlan:
\nDiagnostic Plan: Urinalysis, urine culture and sensitivity
\nTreatment Plan: Ciprofloxacin 500mg PO BID for 7 days.<\/p>\n
Patient Education: Importance of taking all antibiotics as prescribed. Drink plenty of water and cranberry juice. Call if symptoms worsen or do not improve in 2-3 days.
\nReturn in 2 weeks for recheck or sooner if symptoms persist.
\nReferences:
\nCenters for Disease Control and Prevention. (2022, May 18). Urinary tract infection (UTI) statistics. https:\/\/www.cdc.gov\/nchs\/fastats\/urinary-tract-infections.htm
\nMayo Clinic. (2022, June 11). Urinary tract infections (UTIs) in adults. https:\/\/www.mayoclinic.org\/diseases-conditions\/urinary-tract-infection\/symptoms-causes\/syc-20353447
\nMedlinePlus. (2022, June 7). Urinary tract infection. https:\/\/medlineplus.gov\/urinarytractinfections.html
\nNational Kidney Foundation. (2020). Urinary tract infections in adults. https:\/\/www.kidney.org\/atoz\/content\/urinary-tract-infections-adults<\/p>\n","protected":false},"excerpt":{"rendered":"
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