Nursing week 4 assignment

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 Top of Form