Write a Total of 2 Short Clinical Note (You may choose any case you like as long as its an office visit Family Practice setting. A standard Clinical Soap Note has been provided below as a guide. Remember to have fun and be as creative as you like with each case. Each note can be 200 words
Tips: Need PE charted and dosing and frequency of meds and vital signs. Word normal is not acceptable, you need to describe your review of systems and your physical exam, and patient also needs follow-up want more detail in your notes so any other provider can pick up where you let off they are seen by someone else.
Clinical Notes – This should be a standard clinical SOAP Note (Example Attached)
S: To include the CC: "In patient quotes" and the HPI: To include all aspects of OLDCARTS or PQRST and pertinent ROS. Be sure that there are pertinent positives and negatives as it relates to the diagnosis. This reflects the clinical decision-making process. All women of childbearing age must that the LMP assessed, especially if they are taking medications.
O: The physical findings as it relates to the type of visit. This also must include pertinent labs and other tests – especially as it relates to the case. Here again there must be pertinent positive and negative findings on the exam for the differential diagnosis.
A: This is the assessment list, including the list of differential diagnoses. It is good if the plan is under each of the differential diagnosis. This shows critical thinking processes. There should also be the ICD 10 and CPT codes for each of the items.
P: The plan must include including medications, testing, procedures, referrals, education, ect. Be sure it includes the follow-up. Indicate if the designated treatment plan was the preceptors, or theirs. If it was the preceptor’s would their plan be different. Make sure there is clear description of the clinical reasoning. How was the differential diagnosis ruled in or ruled out? How was the treatment plan determined?