Make a SOAP notes reflective of the patient care experience

Make a SOAP notes reflective of the patient care experience in the clinical setting: WELL CHILD VISIT/ANNUAL PHYSICAL EXAM ONLY! It should include complete subjective and objective information to support the assessment and plan. The plan must include diagnostic and treatment measures, patient education, and follow-up. Include the following: Subjective findings Chief complaint (CC) History of present illness (HPI) Use mnemonic: onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, and severity (OLDCARTS) Past medical/surgical/social/family history Medications Allergies, prescription/over the counter (OTC)/herbal medications Comprehensive review of systems (ROS) Objective findings Appropriate physical examination based on subjective findings Relevant positive and negative diagnostic testing including previous pertinent diagnostic tests related to visit Screening tools and positive and negative results Assessment Correct primary diagnosis Correct differential diagnoses Correct ICD-10/Current Procedural Terminology (CPT) codes Plan Identify and orders correct diagnostics, prescriptions, referrals, and follow-up plan Patient education relative to treatment plan. Correctly written out a prescription for one medication prescribed for the patient. If a medication not prescribed, write out a prescription for a medication that might be prescribed for a similar patient Include two current evidence-based guidelines and/or peer-reviewed scholarly journals to support patient education and treatment plan. References should be from scholarly peer-reviewed journals and be less than five (5) years old.

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