Mini SOAP Note Essay Paper Assignment
S: C/C sore throat x3 days
O: Vitals; BP: 128/81 RR: 22 Pulse: 86 Temp: 99.2 W: 165 H: 5’3
A: 42-year-old female presented with sore throat x3 days. Normal lips, tongue, gums and healthy teeth; pharynx is erythematous.
P: Labs: Throat culture; negative for Strep
Medication: OTC Tylenol as needed for pain
Education: Take medication as needed. Discussed home remedies such as gargle with warm salt water, use humidifier, and drink plenty of fluids.
Follow-up with office if symptoms persist.
Must contain the ICD 10 diagnosis code for the soap note.
S: Subjective- what and why patient is presented for
O: Objective- Vitals (blood pressure, respiratoty rate, pulse, weight, height, temp)
A: Assessment- Physical findings from exam as well as age of patient and diagnosis
P: Plan- must address lab and/or diagnostic testing, medication being prescribed, patient education based on ICD 10 diagnosis code, follow instructions and if a referral is needed must be noted in SOAP note. Hence, must only use elder patients.
Mini SOAP Note
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