36-year-old female G1P1 LMP 10/1/2021
Painful menses each month. No relief with OTC pain medications
Sexually active with 2 male partners. Painful intercourse
Does not use condoms
Severe pain at ovulation
Med History – make up answers for her.
Include vital signs
Include point of care testing (POCT) (if appropriate)
Include an appropriate exam
Include ICD 10 code
Include medication (if appropriate)
Include education, teaching, follow-up, and referral (if appropriate)
Problem-Focused SOAP Note Format
Patient initial (one initial only), age, and gender must be HIPAA compliant.
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
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)
Physical findings listed by body systems, not paragraph form
Assessment (the diagnosis)
Three (3) differential diagnoses (if applicable) with rationale
Final diagnosis with rationale and pathophysiological explanation
Dx Plan (lab, x-ray)
Tx Plan (meds)
Pt. Education, including specific medication teaching points
Health maintenance (including when screenings, immunizations, etc., are next due):
Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.
EXAMPLES ARE LISTED BELOW!!!!!