Complete a problem – focused SOAP note. Please follow the template attached. Case will be provided
Demographic Data
Age, and gender (must be HIPAA compliant)
Subjective

Chief Complaint (CC) unless an Annual Physical Exam (APE)

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, sexual hx, occupation, school, etc.
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)

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