CASE SCENARIO

Complete all the requirements of the case scenario.

Use at least one scholarly source 

• PLEASE USE THE TEMPLATE BELOW FOR THE SOAP NOTE SECTION 
• 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
• 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