Assignment Criteria: Students will complete a Soap note and include the following: 1. Subjective findings a. Chief complaint (CC) b. History of present illness (HPI) i. Use mnemonic (when appropriate): onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, and severity (OLDCARTS) for acute symptoms ii. Include pertinent positives and negatives c. Relevant past medical/surgical/social/family history d. Medications i. Allergies, prescription/over the counter (OTC)/herbal medications e. Relevant review of systems (ROS)
2. Objective findings a. Appropriate physical examination based on subjective findings b. Relevant positive and negative diagnostic testing including previous pertinent diagnostic tests related to visit c. Screening tools and positive and negative results
3. Assessment a. Correct primary diagnosis b. Correct differential diagnoses
c. Correct ICD-10/Current Procedural Terminology (CPT) codes
4. Plan a. Identify and orders correct diagnostics, prescriptions, referrals, and follow-up plan b. Patient education relative to treatment plan. c. Correctly written out a prescription for one medication prescribed for the patient. i. 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.
6. APA format required (attention to spelling/grammar, a title page, a reference page, and in-text citations
Patient: [Patient Name]
Date: [Date of Visit]
a. Chief Complaint (CC): The patient presents with [chief complaint].
b. History of Present Illness (HPI):
Onset: The symptoms started [time of onset].
Location/Radiation: The patient experiences [location of symptoms] that may radiate to [radiation location].
Duration: The symptoms have been present for [duration].
Character: The patient describes the symptoms as [character].
Aggravating Factors: The symptoms are aggravated by [aggravating factors].
Relieving Factors: The symptoms are relieved by [relieving factors].
Timing: The symptoms occur [timing].
Severity: The intensity of the symptoms is [severity].
Pertinent positives include [list of pertinent positives].
Pertinent negatives include [list of pertinent negatives].
c. Relevant Past Medical/Surgical/Social/Family History: The patient has a past medical history of [relevant medical conditions], surgical history of [relevant surgeries], social history of [relevant social factors], and family history of [relevant family medical history].
Allergies: The patient has allergies to [allergies].
Prescription Medications: The patient takes [prescription medications].
Over the Counter (OTC)/Herbal Medications: The patient uses [OTC/herbal medications].
e. Relevant Review of Systems (ROS): The patient reports [relevant review of systems findings].
a. Physical Examination: The physical examination reveals [findings from the examination].
b. Diagnostic Testing: Relevant diagnostic testing includes [results of diagnostic tests].
c. Screening Tools: [Screening tools used] show [positive/negative results].
a. Primary Diagnosis: The primary diagnosis for the patient is [diagnosis].
b. Differential Diagnoses: The differential diagnoses considered are [differential diagnoses].
c. ICD-10/CPT Codes:
ICD-10 Code: [ICD-10 code]
CPT Code: [CPT code]
a. Diagnostics, Prescriptions, Referrals, and Follow-up Plan: The following are ordered:
Diagnostics: [Diagnostic tests ordered]
Prescriptions: [Prescriptions ordered]
Referrals: [Referrals made]
Follow-up Plan: The patient is advised to follow up [follow-up instructions].
b. Patient Education: The patient will be educated regarding the treatment plan, including [patient education topics].
Medication: [Medication Name]
Route: [Route of Administration]