Example Mini SOAP Note
ICD 10: J02.9
S: C/C sore throat x3 days
O: Vitals; BP: 128/81 RR: 22 Pulse: 86 Temp: 99.2 W: 165 H: 5’3
A: 42-year-old female presented with sore throat x3 days. Normal lips, tongue, gums and healthy teeth; pharynx is erythematous.
P: Labs: Throat culture; negative for Strep
Medication: OTC Tylenol as needed for pain
Education: Take medication as needed. Discussed home remedies such as gargle with warm salt water, use humidifier, and drink plenty of fluids.
Follow-up with office if symptoms persist.
Must contain the ICD 10 diagnosis code for the soap note.
S: Subjective- what and why patient is presented for
O: Objective- Vitals (blood pressure, respiratoty rate, pulse, weight, height, temp)
A: Assessment- Physical findings from exam as well as age of patient and diagnosis
P: Plan- must address lab and/or diagnostic testing, medication being prescribed, patient education based on ICD 10 diagnosis code, follow instructions and if a referral is needed must be noted in SOAP note. Hence, must only use elder patients.
Do you need help with this assignment or any other? We got you! Place your order and leave the rest to our experts.