mini soap note

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 

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