Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit as a Word Document. See example template below for required format.<\/p>\n
32 y\/o female G4P2 presents to clinic at 10 weeks gestation. please fill in the rest with relevant information.<\/p>\n
Review the rubric for more information on how your assignment will be graded.<\/p>\n
Demographic Data<\/p>\n
Age, and gender (must be HIPAA compliant)
\nSubjective<\/p>\n
Chief Complaint (CC) unless an Annual Physical Exam (APE)
\nHistory of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating\/Alleviating Factors, Relieving Factors, Treatment)
\nPast Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance as applicable
\nFamily Hx: As applicable
\nSocial Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
\nReview of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
\nObjective<\/p>\n
Vital signs
\nPhysical findings listed by body systems, not paragraph form
\nAssessment (Diagnosis\/ICD10 Code)<\/p>\n
Include all diagnoses that apply for this visit
\nPlan<\/p>\n
Dx Plan (lab, x-ray)
\nTx Plan: (meds)
\nPt. Education, including specific medication teaching points
\nReferral\/Follow-up
\nHealth maintenance (including when screenings, immunizations, etc., are next due):<\/p>\n
______________________
\nWriting Guide:
\nDemographic Data
\n32 year old female
\nSubjective
\nChief Complaint: Routine prenatal care visit at 10 weeks gestation
\nHistory of Present Illness: Patient presents for her initial prenatal care appointment. She reports her last menstrual period began on November 15th and she experienced normal menstrual cycles of 28 days prior to conception. She has experienced mild nausea and fatigue but no vomiting.
\nPast Medical History: Unremarkable
\nFamily History: Mother with gestational diabetes
\nSocial History: Married, lives with husband. Smokes half a pack of cigarettes daily. Works as an accountant.
\nReview of Systems: Negative except for nausea and fatigue as noted in HPI
\nObjective
\nVital Signs: BP 110\/70, Pulse 80, Temp 98.6 F
\nPhysical Exam: Fundal height measures 10 weeks. Fetal heartbeat detected via Doppler at 140 bpm. Breast exam normal. Neurological and cardiovascular exams unremarkable.
\nAssessment
\nICD-10: O09.00, Normal pregnancy, 10 weeks
\nPlan
\nDiagnostic Plan: Order prenatal panel labs, schedule anatomy ultrasound for 18-20 weeks
\nTreatment Plan: Start prenatal vitamins, discuss smoking cessation counseling\/resources
\nPatient Education: Review early pregnancy symptoms, discuss importance of folic acid, discuss smoking risks and goal to quit, schedule next prenatal visit
\nReferrals\/Follow Up: Schedule next prenatal visit in 4 weeks. Refer to smoking cessation program.
\nHealth Maintenance: Schedule Pap smear, discuss breast self exams<\/p>\n","protected":false},"excerpt":{"rendered":"
Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit as a Word Document. See example template below for required format. 32 y\/o female G4P2 presents to clinic at 10 weeks gestation. please fill in the rest with relevant information. Review the rubric for more information on how your assignment […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[4688,12402,11989,1797,1799,1803],"tags":[],"class_list":["post-138707","post","type-post","status-publish","format-standard","hentry","category-focused-soap-note","category-mini-soap-note-example-answer","category-shadow-health-soap-note","category-soap-note","category-soap-note-assignment-writing-help","category-soap-note-example"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/posts\/138707","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/comments?post=138707"}],"version-history":[{"count":1,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/posts\/138707\/revisions"}],"predecessor-version":[{"id":138708,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/posts\/138707\/revisions\/138708"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/media?parent=138707"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/categories?post=138707"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/tags?post=138707"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}