Mini-SOAP Note Submission: Clinical Case Documentation and Analysis

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.

Review the rubric for more information on how your assignment will be graded.

Demographic Data 

· Patient initial (one initial only), age, and gender must be Health Insurance Portability and Accountability (HIPPA) compliant.

Subjective 

· Chief Complaint (CC)

· History of Present Illness (HPI) (symptoms) in paragraph format

· Past Medical History (PMH): Current problem-focused and document pertinent information only.

· Current Medications:

· Medication Allergies:

· Social History: For current problem-focused and document only pertinent information only.

· Family History: For current problem-focused and document only pertinent information only.

· Review of Systems (ROS) as appropriate:

Objective 

· Vital signs

· Mental Status Exam

· Physical findings listed by body systems, not paragraph form.

· Patient Health Questionnaires, Screenings, and the results (PHQ-9, GAD 7, suicidal)

Assessment (Diagnosis/ICD10 Code) 

· Include all diagnoses that apply to this visit.

· Include one differential diagnosis.

Plan 

· Dx Plan (lab, x-ray)

· Tx Plan: (meds)

· Pt. Education, including specific medication teaching points.

· Safety Plan

· Referral/Follow-up

*Based on population focus, some additional details may be required by faculty Top of Form