Write a SOAP Note for a 13 year old male patient presenting with symptoms of right knee
pain and swelling
Follow these Rubrics and the attached template !!!!!
Chief Complaint
Includes a direct quote from the patient about the presenting problem.
Demographics
Begins with patient initials, age, race, ethnicity, and gender (5 demographics).
History of the Present Illness
Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity).
Allergies
Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy).
Review of Systems
Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to chief complaint AND uses the words “admits” and “denies”.
Vital Signs
Includes all 8 vital signs,
(BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population), and pain).
Labs 3
Includes a list of the labs reviewed at the visit, values of lab results, and highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed.
Medications
Includes a list of all of the patient-reported medications and the medical diagnosis for the medication (including name, dose, route, and frequency).
Screenings
Includes an assessment of at least 5 screening tests
Past Medical History
Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis, and whether the diagnosis is active or current.
Past Surgical History
Includes, for each surgical procedure, the year of the procedure, and the indication for the procedure.
Family History
Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease, and cancer.
Social History
Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.
Physical Examination
Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to the chief complaint.
Diagnosis
Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority).
Differential Diagnosis
Includes at least 3 differential diagnoses for the principal diagnosis
Pharmacologic Treatment Plan
Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the following: drug name, dose, route, frequency, duration, and cost as well as education related to pharmacologic agents. If the diagnosis is a chronic problem, the student includes instructions on currently prescribed medications as above.
Diagnostic/Lab Testing
Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”
Education
Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives.
Anticipatory Guidance
Includes at least 3 primary prevention strategies (related to age/condition (i.e., immunizations, pediatric and pre-natal milestone anticipatory guidance), and at least 2 secondary prevention strategies (related to age/condition (i.e., screening).
Follow-up plan
Includes recommendation for follow-up, including time frame (i.e., x # of days/weeks/months).
References -High level of APA precision.
Grammar -Free of grammar and spelling errors.
