Episodic SOAP Note

complete a Soap note and include the following: 1.Subjective findings Chief complaint (CC) History of present illness (HPI) Use mnemonic: onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, and severity (OLDCARTS) Past medical/surgical/social/family history Medications Allergies, prescription/over the counter (OTC)/herbal medications Comprehensive review of systems (ROS) 2. Objective findings Appropriate physical examination based on subjective findings Relevant positive and negative diagnostic testing including previous pertinent diagnostic tests related to visit Screening tools and positive and negative results 3.Assessment Correct primary diagnosis Correct differential diagnoses Correct ICD-10/Current Procedural Terminology (CPT) codes 4. Plan Identify and orders correct diagnostics, prescriptions, referrals, and follow-up plan Patient education relative to treatment plan. Correctly written out a prescription for one medication prescribed for the patient. If a medication not prescribed, write out a prescription for a medication that might be prescribed for a similar patient 5. Include two current evidence-based guidelines and/or peer-reviewed scholarly journals to support patient education and treatment plan. The student can pick one evidence-based guideline and one scholarly article. References should be from scholarly peer-reviewed journals (check Ulrich's Periodical Directory) and be less than five (5) years old.