DUE 6/2/2023.....PLEASE FOLLOW ALL INSTRUCTIONS......READ ALL ATTACHMENTS

SOAP NOTE TEMPLATE (Episodic/Problem Visit)

Student Name: Date: Course:

Patient Demographics: (age, gender, ethnicity, etc.)

Chief Complaint: “quote patient”

History of Present illness: 7 attributes required

Past Childhood Illnesses: measles, mumps, rubella, varicella, scarlet fever, rheumatic fever, polio, and any other childhood illnesses such as Asthma

PMH: dates in reverse chronological order.

PSH: surgery dates in reverse chronological order.

Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies

Untoward Medication Reactions: include type of reaction/severity/date

Immunization Status: e.g. Flu, Prevnar 13, TdaP, etc. Date must be included

Screenings: e.g. Newborn screening, vision screening, dental visits, TB screening/PPD, etc… (Indicate if results were normal or abnormal)

FMH: include relevant genetic risk history for living/deceased immediate relatives including grandparents, parents, siblings, children, grandchildren; for deceased relatives include cause of death and age; for sick relatives include age of onset

Personal History/Social History: family relationship status, children, occupation, living arrangements, exercise, personal interests, religion, illicit drug use, tobacco-use in pack years, if stopped smoking for how long did they smoke and when did they quit smoking; alcohol use—how many drinks/week, type of alcohol

Females: LMP and relevant OB/GYN history Gravida, Para, Abortions-spontaneous vs. induced

age of menarche, duration of period, avg. length of cycles, flow, etc

Sexual History: #of partners, sex of partner/s, protected/unprotected sexual relations, contraception

Current Medications/OTCs/Supplements: indicate Dose, Route, Frequency (write class of medication in parentheses):

For Episodic Visit, only list ROS/PE that are pertinent to CC/HPI.

Review of Systems:

General:

Skin:

HEENT:

Head:

Eyes:

Ears:

Nose:

Throat:

Breasts:

Respiratory:

Cardiovascular:

Gastrointestinal:

Genitourinary:

Peripheral Vascular:

Musculoskeletal:

Neurologic:

Hematologic:

Lymphatic:

Endocrine:

Psychiatric:

Screening Tool: ONE screening tool is required and it should be scored (e.g. PHQ-2 Depression Scale, CRAFFT, etc.)—if screening is positive list as a diagnosis with a plan.

For Episodic Visit, only list ROS/PE that are pertinent to CC/HPI.

Physical Exam:

Vital Signs: Blood Pressure- P- RR- T- Pain- Height- Weight- BMI-

General:

Skin:

HEENT:

Head:

Eyes:

Ears:

Nose:

Throat:

Neck:

Breasts:

Lungs:

Heart:

Abdomen:

Genitourinary:

Rectal:

Peripheral Vascular:

Lymphatic:

Extremities: Musculoskeletal:

Neurological:

Pertinent Labs/Diagnostic Testing: Indicate any previous labs or diagnostics done that are relevant to today’s visit, as well as any Point of Care Testing (POCT) done during the visit with results.

Differential Diagnosis Diagnostic Reasoning Exercise: Minimum of 3 differential diagnoses/maximum of 5 differentials—the table will help with the narrative write-up required below the table.

Differential Diagnoses	Pathophysiology (include APA citations)	Pertinent Positives	Pertinent Negatives
1.
2.
3.
4.
5.

In a narrative format explain how you arrived at your final diagnosis or working diagnoses based on the CC/HPI, PMH, PSH, ROS, & Physical Exam (pertinent +/– will guide this process). This should be written using examples of how the history/clinical presentation led to the final diagnosis or working diagnosis (APA citations to your references must be included – use resources with Evidence Based Guidelines)

Assessment/Plan:

Include a brief summary of the visit here

(APA citations required in your plan)

List diagnoses applicable to your patient encounter. Diagnosis #1 is your primary/working diagnosis made at the time of the visit. If you have not made a diagnosis, then you would use the ICD-10 code for the symptomatology since r/o diagnoses are not billable. This should be followed by a plan of care that is evidenced based.

Diagnosis # 1 ICD-10 (must be related to CC/HPI)

a. Plan listed here (plan should be evidenced based, if not, state why the plan deviated from the evidence)

b.

c.

Diagnosis # 2 ICD-10 may be a chronic condition which is being followed-up (e.g. Asthma, diabetes)

a. Plan listed here

b.

c.

Diagnosis # 3 ICD-10 may be a chronic condition which is being followed-up (e.g. HTN, Asthma)

a. Plan listed here

b.

c.

Health Maintenance: Required App for USPSTF screening guidelines https://epss.ahrq.gov/PDA/index.jsp

Must list all screenings/lifestyle recommendations that are age appropriate (e.g. seasonal flu vaccine, HIV screening; STI screenings, obesity—nutritional/exercise counseling; smoker—tobacco cessation program, etc.)

RTC: (Document disposition)

References (APA Format)

FACULTY ONLY

Grade __________