MDC Patient with Generalized Anxiety Disorder SOAP Note

Submit 1 Mini-SOAP note on a patient that you saw in clinic this week.

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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