w2 mini soap note

Make up patient info.

Chief complaint- Ive been having symptoms of PCOS like facial hair growth and acne.

Diagnosis PCOS E28.2

Demographic Data

Patient initial (one initial only), age, and gender must be HIPAA compliant

Subjective

Chief Complaint (CC)

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 are listed by body systems, notin paragraph form
• Assessment (Diagnosis/ICD10 Code)
• Include all diagnoses that apply for this visit

Plan

Dx Plan (lab, x-ray)

• Tx Plan: (meds)
• Education, including specific medication teaching points           

Referral/Follow-up

Health Maintenance (including when screenings, immunizations, etc.