Demographic Data Patient initial (one initial only), age, and gender must be HIP

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 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):
PATIENT
SOAP NOTE PATIENT
DOB: 16 Nov 2002 (20 yo ) MALE
CC
Establish care
Physical exam
Subjective
The patient is a 20-year-old male with a past medical history of GAD and Asthma who was evaluated today via office visit to establish care.
The patient feels well otherwise.
PMHx
Asthma
Generalized Anxiety Disorder
PSHx
No past surgical history has been documented for this patient
FHx
father: Alive, -Colon CA, -Prostate CA
mother: Alive, -Breast CA, -Colon CA, -Ovarian CA, -Uterine CA
Soc Hx
Alcohol: Do not drink
Birth Gender: Male
Drug Abuse: No illicit drug use
Tobacco: Never smoker
ROS
CONSTITUTIONAL: No fever. No chills. No dizziness. No weakness.
EYES: No pain, erythema, or discharge. No blurring of vision.
ENT: No sore throat, URI symptoms. No epistaxis. No tinnitus.
CARDIOVASCULAR: No chest pain. No palpitations. No lower extremity edema.
RESPIRATORY: No hemoptysis. No dyspnea. No paroxysmal nocturnal dyspnea.
GASTROINTESTINAL: Normal appetite. No nausea, vomiting, diarrhea. No pain. No bloating. No melena.
GENITOURINARY: No frequency, urgency, nocturia. No hematuria or dysuria.
MUSCULOSKELETAL: No joint swelling.
INTEGUMENTARY: No swelling. No bruising. No contusions. No abrasions. No lymphangitis.
NEUROLOGIC: No headache. No neck pains. No numbness or tingling of the extremities. No weakness.
PSYCHIATRIC: No confusion.
ENDOCRINE: No fatigue. No weakness.
HEMATOLOGICAL: No bleeding. No petechiae. No bruising.
Medications
albuterol sulfate 2.5 mg/3 mL (0.083 %) solution for nebulization, 1 neb(s) inhaled 4 times a day as needed (Edited by Maher Danhash on 10 Feb, 2023 at 05:11 PM )
nebulizer and compressor, neb tx QID (Edited by Maher Danhash on 10 Feb, 2023 at 05:09 PM )
Wellbutrin XL 150 mg 24 hr tablet, extended release, 1 tab(s) orally once a day (Edited by Maher Danhash on 10 Feb, 2023 at 05:08 PM )
Asmanex HFA 200 mcg/actuation aerosol inhaler, 2 puff(s) inhaled 2 times a day (Edited by Maher Danhash on 10 Feb, 2023 at 05:08 PM )
montelukast 10 mg tablet, 1 tab(s) orally once a day (Edited by Maher Danhash on 10 Feb, 2023 at 05:07 PM )
albuterol sulfate HFA 90 mcg/actuation aerosol inhaler, 2 puff(s) inhaled 4 times a day as needed (Edited by Maher Danhash on 10 Feb, 2023 at 05:06 PM )
Allergies
No allergy history has been documented for this patient.
Mental/Functional
The patient’s speech was normal, sharing conversation with normal laryngeal efforts. Appropriate mood and affect were seen on exam. Thought processes were logical, relevant, and thoughts were completed normally. Thought content was normal. Thought content was normal with no psychotic or suicidal thoughts. The patient’s judgement was realistic with normal insight into their present condition. Mental status included: correct time, place, person orientation, normal recent and remote memory, normal attention span and concentration ability. Language skills included the ability to correctly name objects. Fund of knowledge included normal awareness of current and past events.
Vitals
Objective
GENERAL: The patient is well-developed and nontoxic.
HEENT: Moist mucous membrane
CHEST: The chest wall is nontender.
HEART: Regular rate and rhythm without murmurs.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, positive bowel sounds, nontender, no organomegaly.
SKIN: No rash, no excessive bruising, petechiae, or purpura.
NEUROLOGIC: Cranial nerves II-XII intact without motor/sensory deficit.
Tests
PHQ-9 Total score: 0
Negative results
Assessment
Generalized anxiety disorder (disorder) (F41.1/300.02) Generalized anxiety disorder modified 11 Feb, 2023
Mild intermittent asthma (disorder) (J45.20) Mild intermittent asthma, uncomplicated modified 11 Feb, 2023
Standardized adult depression screening tool completed (situation) (Z13.89/V79.0) Encounter for screening for other disorder modified 10 Feb, 2023
Encounter for general adult medical exam w abnormal findings (Z00.01/V70.0) Encounter for general adult medical exam w abnormal findings modified 10 Feb, 2023
Plan
Generalized anxiety disorder (disorder)
No anxiety attacks, start Wellbutrin XL 150 mg 24 hr tablet, extended release, 1 tab(s) orally once a day
Mild intermittent asthma (disorder)
Start Asmanex HFA 200 mcg/actuation aerosol inhaler, 2 puff(s) inhaled 2 times a day
montelukast 10 mg tablet, 1 tab(s) orally once a day
albuterol sulfate HFA 90 mcg/actuation aerosol inhaler, 2 puff(s) inhaled 4 times a day as needed
Standardized adult depression screening tool completed (situation)
Negative screening for depression
Encounter for general adult medical exam w abnormal findings
Normal exam except for the above findings

The patient verbalized understanding of what we discussed today.
The patient will schedule a follow-up appointment at their convenience time.
Side effects of medications were discussed with the patient with good effective communication.
I discussed findings and treatment options with the patient, including their risks and benefits. The importance of compliance was discussed and discussed possible side effects of medications. Therapeutic lifestyle changes include a healthy diet, regular exercise program, adequate daily hydration, and maintenance of ideal body weight.
Risks and benefits are explained, and the patient understands the importance of medication adherence, drug-drug interaction, and possible side effects.
Effective communication was attempted slowly, clearly, using simple language word repetition as needed, and the patient voiced understanding and agreed with the plan of care.
The patient was advised to notify me of any new symptoms or signs.
Advised patient to follow up with his pharmacy for all recommended vaccines for his/her age.
This report was transcribed using voice recognition and auto-fill technology and may contain unforeseen errors due to limitations in the technology, ambient noise, or vendor settings. If errors are noted, please notify my clinic.
Time spent statement: Total time for today’s visit was 45 minutes. This includes face-to-face time and non-face-to-face time spent reviewing the test, obtaining and reviewing separately obtained history, performing a medically necessary review appropriate examination and evaluation, counseling and educating the patient, family, or caregiver, and ordering medication, test, or procedures.
MAKE IT LOOK LIKE THIS!!!!!!!
Pediatric Sample Mini SOAP #2
Patient: 10 months male
Subjective
CC: coughing and wheezing x 3 days
HPI: 10-month-old male brought in by father with cough x 3 days and
wheezing past 24 hours. +Post-tussive emesis, +moist cough day & night,
getting worse.
-rhinorrhea, +wheezing since last night, denies prior hx wheezing,
+Fever, T-max 101 F, denies diarrhea, ill family members. +normal fluid
intake and urine output, +decreased appetite
PMH: Denies, born FT/healthy
MEDS: Tylenol for fever
Allergies- none
Objective
Vitals: T = 102 F (ear) P= 150 RR = 48 B/P = N/A Length/Ht. = 29” (50%) Wt.: 9.2kg
(50%)
Pulse Ox = 92%
General: WNWD male, moderate resp. distress, alert, non-toxic appearing
HEENT: NCNT, Left TM red/dull, RT TM clear, PERRL, +Red Reflex Bilat, nose
w/o dc, pink OP, neck supple
Heart: RRR, no murmur, cap refill or = 101 F or pain. Apply warm compress to
affected ear as needed for pain. Return to clinic tomorrow for recheck.
Go to ED prn labored breathing, sxs worsen.