Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit here as a Word Document. See the example template below for the required format.
Patient seen is a 53 y/o female complaining of burning sensation while urinating.
Dx: UTI
please complete the mini SOAP below.
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Problem-Focused SOAP Note Format
Demographic Data
Age, and gender (must be HIPAA compliant)
Subjective
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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):
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A mini-SOAP note for the 53-year-old female patient complaining of burning sensation while urinating:
Demographic Data:
53-year-old female
Subjective:
Chief Complaint (CC): Burning sensation while urinating
History of Present Illness (HPI): Patient reports experiencing burning pain with urination for the past 2 days. The burning is constant and worsens with urination. She denies any other symptoms.
Past Medical History (PMH): Hypertension, diabetes
Family History (FH): Mother with history of breast cancer
Social History (SH): Married, retired teacher. Does not smoke or drink.
Objective:
Vital Signs: Temp 98.6 F, BP 140/90, Pulse 80, Respirations 18
Physical Exam: General exam unremarkable. Abdomen soft, non-tender. Normal female genitalia on exam.
Assessment:
Urinary tract infection (UTI) (N39.0)
Plan:
Diagnostic Plan: Urinalysis, urine culture and sensitivity
Treatment Plan: Ciprofloxacin 500mg PO BID for 7 days.
Patient Education: Importance of taking all antibiotics as prescribed. Drink plenty of water and cranberry juice. Call if symptoms worsen or do not improve in 2-3 days.
Return in 2 weeks for recheck or sooner if symptoms persist.
References:
Centers for Disease Control and Prevention. (2022, May 18). Urinary tract infection (UTI) statistics. https://www.cdc.gov/nchs/fastats/urinary-tract-infections.htm
Mayo Clinic. (2022, June 11). Urinary tract infections (UTIs) in adults. https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447
MedlinePlus. (2022, June 7). Urinary tract infection. https://medlineplus.gov/urinarytractinfections.html
National Kidney Foundation. (2020). Urinary tract infections in adults. https://www.kidney.org/atoz/content/urinary-tract-infections-adults
