For this assignment, students will create ONE SOAP notes reflective of the patient care experience in the clinical setting under the
supervision of the clinical preceptor in the role of the clinical provider. This assignment will evaluate the student’s clinical reasoning
skills, interviewing skills, physical exam skills, selection of diagnostic testing, differential diagnosis, pharmaceutical and non-
pharmaceutical treatment, patient education, and follow-up plan.
Students must develop the clinical skills and knowledge required for safe practice and deliver best patient outcomes upon graduation.
SOAP notes should be used to document each patient seen in the clinical setting. Clear, concise, and thorough documentation is
required for continuity of care, safe practice, appropriate reimbursement, and prudent risk management.
When developing the SOAP note, students should use the assignment criteria below and the ACON SOAP Note Template found in
Modules/Week X. Students should include complete subjective and objective information to support the assessment and plan. The
plan must include diagnostic and treatment measures, patient education, and follow-up.
Keep the following points in mind:
Use the ACON SOAP Note template as a guide
Identify and collect relevant subjective and objective data.
Use proper medical terminology and documentation.
Use proper ICD-10 coding and Current Procedural Terminology (CPT) E/M coding.
Identify any cultural/religious/racial/gender influences on care.
Assignment Criteria:
Students will complete a Soap note and include the following:
1. Subjective findings
a. Chief complaint (CC)
b. History of present illness (HPI)
i. Use mnemonic: onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, and
severity (OLDCARTS)
c. Past medical/surgical/social/family history
d. Medications
i. Allergies, prescription/over the counter (OTC)/herbal medications
e. Comprehensive review of systems (ROS)
2. Objective findings
a. Appropriate physical examination based on subjective findings.
b. Relevant positive and negative diagnostic testing including previous pertinent diagnostic tests related to visit.
c. Screening tools and positive and negative results
3.Assessment
a. Correct primary diagnosis.
b. Correct differential diagnoses.
c. Correct ICD-10/Current Procedural Terminology (CPT) codes
4. Plan
a. Identify and orders correct diagnostics, prescriptions, referrals, and follow-up plan.
b. Patient education relative to treatment plan.
c. Correctly written out a prescription for one medication prescribed for the patient.
i. If a medication is not prescribed, write out a prescription for a medication that might be prescribed for a similar
patient.
I’m attaching thetemplate that needs to be used AND an example for a patient that you can use
Please do not leave anything blank, if you do not have the information to fill in the template make it up
Subjective (S): Chief Complaint (CC): Patient was sent by Dr. C’s office due to an open wound on his right leg that may be infected. The patient reports his legs have been swollen for a few days with erythema and heat, and he noticed the wound this morning. History of Present Illness (HPI): This is an 82-year-old male with a significant past medical history of gastritis, duodenitis, hypertension, hyperlipidemia, obesity, and coronary artery disease status post-CABG in 2014. He presents with concerns about an infected wound on his right leg and swelling in both legs. The patient reports noticing swelling and erythema in his legs over the past few days, with the wound becoming apparent this morning. He has a history of cellulitis in the legs in the past, which improved with antibiotics. He denies recent trauma, fever, or chills. On examination, bilateral lower extremity edema and a wound draining clear serous discharge were noted. He has been started on IV antibiotics and will require further management by infectious disease. PMH: Gastritis, duodenitis, hypertension, hyperlipidemia, obesity, coronary artery disease status post-CABG in 2014. Problem List/ Past Medical History: Anasarca CAD (coronary artery disease) Gastritis Inflammatory disorder of lower extremity Pedal edema Rosacea Procedure/ Surgical History: Colonoscopy flex w biopsies (10/16/2018) CABG – Coronary artery bypass graft (2014) ORIF – Open reduction of fracture of elbow with internal fixation (2000) Allergies: Cats (rhinitis), Dog Hair (rhinitis) Social History: Alcohol: Occasional use Tobacco Use: Former smoker, quit more than 30 days ago Nutrition/Health: Caffeine Intake: Not specified Travel History: You/Household traveled in last 30 days? No. Lab Results (Most Recent 36 hrs): Hemoglobin: 14.9 g/dL Hematocrit: 45.1 % WBC: 4.99 K/uL Platelet Count: 198 K/uL Sodium on Blood: 141 mmol/L Potassium on Blood: 4.6 mmol/L Chloride on Blood: 111 mmol/L (High) CO2 on Blood: 30 mmol/L Anion Gap: <1 (Low) Glucose on Blood: 91 mg/dL Creatinine on Blood: 1.3 mg/dL BUN on Blood: 20 mg/dL Calcium (Total): 9.3 mg/dL Diagnostic Results (Last 48 hrs): Chest Single View XR: No evidence of acute intrathoracic pathology. Objective (O): Review Of Systems (ROS): Constitutional: No unexplained weight gain or loss, fevers, chills, fatigue Eye: No recent visual problems ENMT: No ear pain, nasal congestion, sore throat Respiratory: No shortness of breath, cough Cardiovascular: No chest pain, palpitations, leg edema Gastrointestinal: No nausea, vomiting, diarrhea Genitourinary: No dysuria, hematuria Hema/Lymph: Negative for bruising tendency, swollen lymph glands Endocrine: Negative for excessive thirst or urination, heat or cold intolerance Musculoskeletal: No back pain, joint pain, muscle pain Integumentary: Bilateral lower extremity erythema and swelling Neurologic: No history of fainting, memory loss, numbness Psychiatric: No anxiety, depression Allergic/Immun: No nasal allergies, itchy/red eyes, enlarged lymph nodes Physical Exam: Vitals & Measurements: T: 36.4 degC, HR: 67 bpm, RR: 18, BP: 107/90 mmHg, SpO2: 100%, HT: 170 cm, WT: 83.1 kg, BMI: 28.75 General: Alert, well nourished, no acute distress Eye: Pupils equal, normal conjunctiva, no scleral icterus ENMT: Normocephalic, normal hearing, moist oral mucosa, no sinus tenderness Neck: Supple, non-tender, trachea midline Respiratory: Normal respiratory effort, clear to auscultation Cardiovascular: Regular rate and rhythm, no murmur, + pedal edema, and erythema Gastrointestinal: Soft, non-tender, normal bowel sounds Musculoskeletal: No digital clubbing or cyanosis Skin: Skin is warm, no rashes or lesions, bilateral lower extremity erythema and swelling Neurologic: Follows commands, speech clear, face symmetrical Psychiatric: Oriented X3, appropriate mood and affect Medical Decision Making/Reevaluation: Home Medications: Carvedilol 6.25 mg BID Entresto 97 mg-103 mg BID Ezetimibe 10 mg Daily Primidone 250 mg QID Rosuvastatin 20 mg Daily Spironolactone 25 mg Daily Assessment/Plan: Cellulitis of leg: Admit to CDU, consult infectious disease, continue vancomycin, wound cultures. Hypertension: Continue antihypertensives, monitor vital signs. CAD: Continue medical management, follow-up with Dr. Castanes. Gastritis: Continue PPI as needed, follow-up with gastroenterologist. Additional Information: Non-opioid alternatives for pain discussed. Primary care provider notified of admission. Follow Up: Admit to CDU for further management by infectious disease. CODE STATUS FULL CODE
