Submit a problem-focused SOAP note for grading. You must use an actual patient from your clinical practicum who presents with one or more chief complaints. 13 year old boy coming for scoliosis screening. On exam, patient have a significant degree of spine curvature. Patient referred to ortho spine specialist. complete the entire attachment with credible resource, make up all points that’s relevant.
Subjective, Objective, Assessment, Plan (SOAP) Notes
Student name:
Patient name (initials only):
Ethnicity:
Course:
Date:
Age:
Time:
Sex:
SUBJECTIVE
CC:
HPI:
Medications:
Past medical history:
Allergies:
Birth hx: (use only on well child visits):
Immunizations:
Hospitalizations:
Past surgical history:
Social history:
Developmental Assessment: (include on well child visit only but may be necessary for problem
focused notes)
FAMILY HISTORY
Mother:
MGM:
MGF:
Father:
PGM:
PGF:
REVIEW OF SYSTEMS
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary/Gynecological:
Musculoskeletal:
Neurological:
Psychiatry:
OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for
well child exam)
Weight:
Height:
BMI:
BP:
Temp:
Pulse:
Resp:
General:
Skin:
Eyes:
Ears:
Nose/Mouth/Throat:
Breast: Heme/Lymph/Endo:
(Insert plotted growth chart below on all well child soap notes)
General appearance:
Skin:
HEENT:
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Labs performed in office the day of visit:
Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or
ruled out)
Differential diagnoses:
Diagnosis (ICD 10 code and reference):
1. Diagnosis, (ICD 10 code and reference):
2. Diagnosis, (ICD 10 code and reference):
3. Diagnosis (ICD 10 code and reference):
Plan/therapeutics/diagnostics;
Education provided:
CPT Code:
Anticipatory guidance (well child visit only)
References: