Patient initial (one initial only), 8 age, and Female gender must be HIPAA

Posted: February 25th, 2023

MINI SOAP NOTE:
WELLNESS EXAMINATION
Demographic Data
Patient initial (one initial only), 8 age, and Female gender must be HIPAA compliant
Subjective
Chief Complaint (CC)
History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)
Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance as applicable
Family Hx: As applicable
Social Hx: Including nutrition, exercise, substance use, school, etc.
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, vaccines)
Objective
Vital signs
Physical findings listed by body systems, not paragraph form
Assessment (Diagnosis/ICD10 Code)
Include all diagnoses that apply for this visit
Plan
Dx Plan (lab, x-ray)
Tx Plan: (meds)
Pt. Education, including specific medication teaching points
Referral/Follow-up
Health maintenance (including when screenings, immunizations, etc., are next due):
*based on population focus, some additional details may be required by faculty
Health maintenance: USPSTF
(Also add the recommendations by USPSTF)

MINI SOAP NOTE:

WELLNESS EXAMINATION

Demographic Data: P, 8-year-old female

Subjective:
CC: Routine wellness examination
HPI: P presents for a routine wellness examination today. She reports feeling well and denies any current symptoms or concerns.
PMH: P has no significant medical or surgical history. She takes a daily multivitamin and has no known allergies. She is up-to-date on all immunizations, including influenza vaccine this season.
Family Hx: Mother has a history of asthma and father has a history of hypertension. No other significant family history reported.
Social Hx: P eats a balanced diet and enjoys playing outside with friends. She is currently in second grade and is doing well in school. She denies any substance use or exposure to secondhand smoke.
ROS: General: P reports no weight changes, fatigue, fever, or chills.
Eyes: P reports no vision changes or eye discomfort.
Ears, Nose, Throat: P denies any ear pain, hearing loss, nasal congestion, or sore throat.
Cardiovascular: P denies any chest pain or palpitations.
Respiratory: P denies any shortness of breath, cough, or wheezing.
Gastrointestinal: P denies any abdominal pain, nausea, vomiting, or diarrhea.
Musculoskeletal: P denies any joint pain or swelling.
Neurological: P denies any headaches or seizures.
Psychiatric: P denies any anxiety or depression symptoms.

Objective:
Vital signs: Blood pressure 100/60 mmHg, heart rate 80 beats per minute, respiratory rate 16 breaths per minute, temperature 98.6°F, and oxygen saturation 98% on room air.
Physical findings: P appears well-developed and well-nourished. Head, eyes, ears, nose, throat, and neck exam are unremarkable. Lungs are clear to auscultation bilaterally. Heart rhythm is regular with no murmurs, rubs, or gallops appreciated. Abdomen is soft and non-tender with no hepatosplenomegaly appreciated. No joint effusions or deformities noted. Neurological exam is grossly normal.

Assessment:

Routine wellness examination
No acute or chronic medical issues identified
Plan:
Dx Plan: None indicated
Tx Plan: None indicated
Pt. Education: Encouraged P to continue eating a balanced diet and getting regular exercise. Provided education on fire safety, bike helmet use, and the importance of hand hygiene.
Referral/Follow-up: Recommended P return in one year for her next routine wellness examination.

Health maintenance:
USPSTF Recommendations:

Obesity screening: Recommend yearly screening for obesity starting at age 6 (Grade B recommendation).
Blood pressure screening: Recommend screening for high blood pressure at least once a year starting at age 3 (Grade A recommendation).
Vision screening: Recommend vision screening at least once between the ages of 3 and 5 years (Grade I recommendation).
Hearing screening: Recommend hearing screening at least once between the ages of 4 and 10 years (Grade I recommendation).
Immunizations: P is up-to-date on all age-appropriate immunizations. Recommend continuing with routine immunizations as recommended by the Centers for Disease Control and Prevention (CDC).