5 yr old female patient presents to the clinic with left ear pain and fever X 2 days. She has been irritable, crying and not eating.
A. Write a SOAP note of a hypothetical case of the above presentation.
B. Document detailed HEENT PE on your SOAP note.
C. Write a substantive response to a minimum of two different students. Is objective and subjective data included in the right format? Please be specific to information related to the SOAP note format.
- Would you agree with your peers differentials listed? Are there any diffs you would add/remove, if so explain your rationale.
- Does HPI have relevant information related to CC?
- Medication listed with right timing, dosing, and number of tablets specified? Any red flags with medication list?
- PMH, FH, and SH has all the appropriate information?
- Does information in ROS correlate to CC?
- Is there any information lacking in physical exam documentation of CC (Students often get confused between ROS and objective findings)?
- Includes assessment, plan, follow up information, and patient education?
See attached sample SOAP Note: Sample_ SOAP_ Note-05f4a4e5-9a1f-4bd4-bb80-1d98c34d9afc.docx” href=”https://samuelmerritt.instructure.com/courses/3281640/files/212511290?verifier=gjphcfyJW6bgS7Ywc71Vi75flCwsBF8VD9VeJMb4&wrap=1″ target=”_blank” data-canvas-previewable=”false” data-api-endpoint=”https://samuelmerritt.instructure.com/api/v1/courses/3281640/files/212511290″ data-api-returntype=”File” rel=”noopener”>Sample_ SOAP_ Note
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