MINI SOAP NOTE:
\nWELLNESS EXAMINATION
\nDemographic Data
\nPatient initial (one initial only), 8 age, and Female gender must be HIPAA compliant
\nSubjective
\nChief Complaint (CC)
\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, school, etc.
\nReview of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, vaccines)
\nObjective
\nVital signs
\nPhysical findings listed by body systems, not paragraph form
\nAssessment (Diagnosis\/ICD10 Code)
\nInclude all diagnoses that apply for this visit
\nPlan
\nDx 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):
\n*based on population focus, some additional details may be required by faculty
\nHealth maintenance: USPSTF
\n(Also add the recommendations by USPSTF)<\/p>\n
MINI SOAP NOTE:<\/p>\n
WELLNESS EXAMINATION<\/p>\n
Demographic Data: P, 8-year-old female<\/p>\n
Subjective:
\nCC: Routine wellness examination
\nHPI: P presents for a routine wellness examination today. She reports feeling well and denies any current symptoms or concerns.
\nPMH: 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.
\nFamily Hx: Mother has a history of asthma and father has a history of hypertension. No other significant family history reported.
\nSocial 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.
\nROS: General: P reports no weight changes, fatigue, fever, or chills.
\nEyes: P reports no vision changes or eye discomfort.
\nEars, Nose, Throat: P denies any ear pain, hearing loss, nasal congestion, or sore throat.
\nCardiovascular: P denies any chest pain or palpitations.
\nRespiratory: P denies any shortness of breath, cough, or wheezing.
\nGastrointestinal: P denies any abdominal pain, nausea, vomiting, or diarrhea.
\nMusculoskeletal: P denies any joint pain or swelling.
\nNeurological: P denies any headaches or seizures.
\nPsychiatric: P denies any anxiety or depression symptoms.<\/p>\n
Objective:
\nVital signs: Blood pressure 100\/60 mmHg, heart rate 80 beats per minute, respiratory rate 16 breaths per minute, temperature 98.6\u00b0F, and oxygen saturation 98% on room air.
\nPhysical 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.<\/p>\n
Assessment:<\/p>\n
Routine wellness examination
\nNo acute or chronic medical issues identified
\nPlan:
\nDx Plan: None indicated
\nTx Plan: None indicated
\nPt. 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.
\nReferral\/Follow-up: Recommended P return in one year for her next routine wellness examination.<\/p>\n
Health maintenance:
\nUSPSTF Recommendations:<\/p>\n
Obesity screening: Recommend yearly screening for obesity starting at age 6 (Grade B recommendation).
\nBlood pressure screening: Recommend screening for high blood pressure at least once a year starting at age 3 (Grade A recommendation).
\nVision screening: Recommend vision screening at least once between the ages of 3 and 5 years (Grade I recommendation).
\nHearing screening: Recommend hearing screening at least once between the ages of 4 and 10 years (Grade I recommendation).
\nImmunizations: 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).<\/p>\n","protected":false},"excerpt":{"rendered":"
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, […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1301,1390,405,452],"tags":[2228,2230,1938,2231,2229],"class_list":["post-4355","post","type-post","status-publish","format-standard","hentry","category-writing-a-soap-note-sample-answers","category-nursing-help-writing-service-usa","category-soap-note-assignment-help","category-write-my-nursing-assignment-paper","tag-8-age","tag-and-female-gender-must-be-hipaa","tag-do-my-homework-for-me","tag-homework-for-you","tag-patient-initial-one-initial-only"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/posts\/4355","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/comments?post=4355"}],"version-history":[{"count":0,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/posts\/4355\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/media?parent=4355"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/categories?post=4355"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/tags?post=4355"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}