USC Health & Medical A Male with Shortness of Breath Soap Note Paper

Write a soap note using this information and the template below:

73 year old Hispanic male comes into the clinic with complaints of a cough that started 5 days ago, shortness of breath, chills and a temperature of 101.2. He has not taken any medications.

Problem-Focused SOAP Note Format

Demographic Data

Age and gender (must be HIPAA compliant)

Subjective

Chief Complaint (CC): A short statement about why they are there

History of Present Illness (HPI): Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment

Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance

Family Hx: any history of CA, DM, HTN, MI, CVA?

Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.

Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)

Objective

Vital Signs

Physical findings listed by body systems, not paragraph form- Highlight abnormal findings

Assessment (the diagnosis)

At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each

Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation

Plan

Dx Plan (lab, x-ray)

Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)

Pt. Education, including specific medication teaching points

Referral/Follow-up

Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due

Reference

Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.

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