Pls do not use the previous template. This is the comment from the instructor.

Comments

The assignment was for a Well-Child SOAP note. Your note was

for a patient presenting with a CC of dysuria which is a problem-

focused visit. Additionally, there were quite a few subjective

components that were not addressed (probably because you

used a universal tempplate). You needed to use the SOAP format

given in the directions because it is specific for pediatrics.

Components such as nutrition, growth and development should

be addressed.

This is the new format.

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

2

• 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.

Problem-focused SOAP Note Problem-focused SOAP Note

Criteria Ratings Pt

s

This criterion is linked to a

Learning Outcome

Subjective

12.5 to >11.5 pts

Accomplished

Symptom analysis is well

organized, with C/C, OLDCART,

pertinent negatives, and pertinent

positives. All data needed to

support the diagnosis & differential

are present. Is complete, concise,

relevant with no extraneous data.

1

2.

5

pt

s

3

This criterion is linked to a

Learning Outcome

Objective

12.5 to >11.5 pts

Accomplished

Complete, concise, well organized

and well written and includes

pertinent positive and pertinent

negative physical findings. Organized

by body system in list format. No

extraneous data.

1

2.

5

pt

s

This criterion is linked to a

Learning Outcome

Assessment

12.5 to >11.5 pts

Accomplished

Diagnosis and differential dx are

correct with ICD code and supported

by subjective and objective data.

1

2.

5

pt

s

This criterion is linked to a

Learning Outcome Plan 12.5 to >11.5 pts

Accomplished

Plan is organized, complete and

evidence-based according to

National Standards of Care.

Addresses each diagnosis and is

individualized to the specific patient

and includes medication teaching

and all 5 components: (Dx plan, Tx

plan, patient education,

referral/follow-up, health

maintenance).

1

2.

5

pt

s

4

Total Points: 50

The case

9 years old hispanic boy

Visited for physical check up

All labs done: CBC, UA, CMP, Lipid panel

Total cholesterol, HDL Cholesterol, Triglyceride were high, and

the rest of the number were all normal. Also, he was obese and

does not like exercise. Low-income family. 3 kids. The youngest is

19 months old. Immigrants.

I do not remember the lab numbers. Pls, you choose it.

Z71.3

Provided counselling for diet and lifestyle changes etc.

Pls research a lot.