Executive Solution Overview
– 2 years ago **files (1)** – ## MINISoapNoteWeek2.pdf **## MINISoapNoteWeek2.pdf** 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, Locat…
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– 2 years ago
**files (1)**
– ## MINISoapNoteWeek2.pdf
**## MINISoapNoteWeek2.pdf**
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):
**## MINISoapNoteWeek2.pdf**
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):
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