Posted: May 1st, 2025

Week 2 Mini Soap Note

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

Demographic Data

Age, and gender (must be HIPAA compliant)

Subjective

Chief Complaint (CC) unless an Annual Physical Exam (APE)

History of Present Illness (HPI) in paragraph form (remember 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 as applicable

• Family Hx: As applicable
• 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

Assessment (Diagnosis/ICD10 Code)

Include all diagnoses that apply for this visit

Plan

Dx Plan (lab, x-ray)

Tx Plan: (meds)

Pt. Education, including specific medication teaching points

Referral/Follow-up

Health maintenance (including when screenings, immunizations, etc., are next due):