Assessment soap note example

Assessment soap note example

Assessment soap note example part of the SOAP NOTE

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Name: Date: Time:
Age: Sex:

Reason given by the patient for seeking medical care “in quotes”



Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.


Medications: (list with reason for med )





Medication Intolerances:


Chronic Illnesses/Major traumas




“Have you every been told that you have:  Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”


Family History Does your mother, father or siblings have any medical or psychiatric illnesses?  Anyone diagnosed with:

lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.


Social History

Education level, occupational history, current living situation/partner/marital status, substance use/abuse,


ETOH, tobacco, marijuana.  Safety status





Weight change, fatigue, fever, chills, night sweats,  energy level



Chest pain, palpitations, PND, orthopnea, edema



Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles



Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB



Corrective lenses, blurring, visual changes of any kind



Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools



Ear pain, hearing loss, ringing in ears, discharge



Urgency, frequency burning, change in color of urine.

Contraception, sexual activity, STDS    Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx

  Male: prostate, PSA, urinary complaints



Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain



Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis


SBE, lumps, bumps or changes


Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells


HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance


Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx



Weight        BMI Temp BP
Height Pulse Resp
General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later.

Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.


Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.

Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.

Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.


Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.


Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.


Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT.

Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.  No adnexal masses or tenderness. Ovaries are non-palpable.

(Male:  both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )

(Rectal as appropriate:  no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).



Full ROM seen in all 4 extremities as patient moved about the exam room.



Speech clear. Good tone. Posture erect. Balance stable; gait normal.



Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab Tests

Urinalysis – pending

Urine culture – pending

Wet prep – pending


Special Tests







 Differential Diagnoses

o    1- o    2- o    3-

Diagnosis (Final)



                        o    Plan:

▪  Further testing

▪  Medication

▪  Education

▪  Non-medication treatments


 Evaluation of patient encounter














Name of assignment

Student Name

Course number and name

Date submitted

Instructor Name

South University, Savannah


South University Family Nurse Practitioner

Universal EPISODIC SOAP Note Template




Revised Winter 2021




Student’s Name:     Sam Student Date:   Date assignment is submitted
Patient / Client initials:    X.X Age:   XX
Gender:             Male           Female             Comment Ethnicity:    XXXX







Chief Complaint (CC)


“My chest hurts and I feel short of breath”



In patient’s own words. Identity and reliability of informant if patient is not informant.


History of Present Illness (HPI)



Onset2 days ago

Location:   sternal chest pain radiating across chest

Durationpresent upon awakening from sleep.  Has been present daily

Characteristicsdull aching pain.  Sometimes it is a sharp pain

Associated S/Sincreased pain with upper body movement, lying down and taking a deep breath.  Feels short of breath when walking but not laying down.  Had a head cold about 2 weeks ago.  Denies fever, chills, cough, runny nose, nasal congestion, rhinitis, nausea, chest wall trauma, and vertigo

Relieving/Aggravating FactorsTylenol 500 every 6 hours helped to decrease pain.  Moist heating pad helps to decrease pain.

Timingacute onset; intermittent pain

Severitypain is 6 out of 10 and decreases to 2 out of 10.  The pain is always present


FBS 115 this morning before eating.  She states they have been running no higher than 140 pre-meal.


Remember to turn the above information into a narrative…

44y/o female presents with a 2 day history of substernal chest pain radiating across the chest. The pain is rated at 2/10 and is present upon waking, described as aching with episodes of sharpness dependent on positioning. Pain is worse with upper body movements, lying down and deep breathing. Associated symptom of shortness of breath with walking. No other associated symptoms reported. Has taken Tylenol 500mf every 6 hours with some relief. In addition, moist heating pad has helped to decrease pain.



For EACH component of the Chief Complaint include all elements (OLDCARTS). Include pertinent positives from the review of systems as they relate to the HPI


Past Medical History (PMH)



Diabetes Mellitus, Diagnosed 2006

Hypertension, 2007

Hyperlipidemia, 2008

GERD, 2021

Influenza B, 2010

Depression (situational r/t death of father, 2012)

Tobacco abuse, started smoking 20 years ago

Acute appendicitis, age 18

Acute cholecystitis, 2010

Colon Cancer, 2014


In chronological order: Current/Past medical problems with date of onset


Past Surgical History (PSH)


Appendectomy, age 18

Cholecystectomy, 2010

Exploratory lap, 2015 for abdominal pain, normal findings

Hospitalized for small bowel resection, colon cancer 2014

Liposuction of abdomen, May 2019


In chronological order: Surgeries and Procedures with date performed and outcome


OB/GYN history

(if applicable)


Gravida 2 Para 2, A 0

LMP:  10 years ago, menopausal

Last PAP:  March 2019, normal findings

Last Mammogram:  Marsh 2019, normal findings

Hx of STD:  negative history of STD


Gravida/Para. Last menstrual period.  Last PAP w/ results. Last Mammogram w/ results.  History of STD


Immunization status


Childhood immunizations completed include smallpox, diphtheria, tetanus, pertussis, polio (OPV), measles, mumps, rubella

Active case of chicken pox, age 8

TdaP, 2017

Pneumovax, 2018

Influenza vaccine contraindicated due to egg allergy


Age specific immunizations, list and describe any history of reactions




Lisinopril 20mg 1 tablet by mouth once a day for essential HTN

Atorvastatin 20mg 1 tablet by mouth at bedtime for hyperlipidemia

Tylenol Extra Strength, 2 tablets by mouth every 6 hours as needed for pain

Pepcid 20mg 1 tablet by mouth twice a day as needed for GERD


Current medications: include medication name, dose, route, frequency, duration, and reason for taking




Allergy to eggs – rash, childhood

Allergy to ACE inhibitors – angioedema, 2010

Not allergic to environment or latex


Medications, Foods, Environmental, Latex and  how allergy is manifested


Family History (FH)


Paternal GF:  deceased age 78 from car accident, CAD, CABG, DM2

Paternal GM:  deceased age 50 from AMI, breast CA

Maternal GF:  living age 85, prostate CA under hospice care

Maternal GM:  deceased age 84 natural causes, hypothyroidism

Father:  living age 68, DM2, Essential HTN, CVA

Mother:  living age 64, essential HTN

Brother:  living, age 42, essential HTN

Sister:  living, age 38, healthy without chronic disease

Daughter (adopted): living age 10, healthy without chronic disease


Blood relatives:  Age, living/deceased, medical problems, Include grandparents, parents,

siblings, and children


Psychosocial or Social History (SH)


Divorced heterosexual female who is not currently in a sexual relationship

1 child – daughter who was adopted at birth

Denies use of illegal or recreational drugs

Drinks 1-2 beers every weekend for at least 20 years

Does not exercise regularly

Eats fast food meals at least 1-2 times per day

Cigarette smoker for 20 years, 1 pack per day.  Not interested in cessation

MSN prepared registered nurse and works as FNP in primary care office

Southern Baptist who does not attend church regularly due to work schedule

Stressors include being single parent with young daughter


Pt. profile (sexual orientation, marital status, children), Lifestyle risk factors (illicit drug use, smoking/pack year, exercise) , Employment history, Education, Religion – beliefs, Cultural history, Support System, Stressors, Driving


Nutritional Screening

when applicable


Screened using Nestle’s Nutritional Screening Tool

Score is 1 of 10 which indicates adequate nutritional status

Area of deficiency was only eating 2 meals per day (skips breakfast)


Report findings from a nutritional screening tool you used to interview patient


Advanced Directives


Has a written Advanced Directive with DPOAHC.  There is not a copy on the chart

She wants her mother to make medical decisions if incapacitated

Wants to have CPR and be placed on ventilator should cardiopulmonary arrest occur


Report patient wishes and initials of decision-maker/relationship of DPOAHC



Episodic visits should include ROS and Physical Exam only for body systems relevant to the complaint


Review your differential diagnosis list and be sure to include all body systems which will adequately evaluate the differential diagnosis

Review of Systems(ROS)
Do not repeat your HPI information in the ROS or physical examination sections.

Typically, only negatives are reported in the ROS.section.

Positives should be reported in the HPI.


Episodic SOAP note should have 3-5 elements addressed in the pertinent body system

Comprehensive SOAP note should have 5-8 elements addressed in the pertinent body system







General statement by the patient (reported symptoms that do not fit one system but often affect overall status)






Eyes, Ears, Nose Throat/Mouth  





Denies radiation of chest pain into jaws or arms, palpitations, racing heart,




Negative for hemoptysis, wheezing, productive cough, exposure to TB




Denies abdominal pain, nausea, vomiting, heartburn, waterbrash.  Chest pain does not occur in relation to meals.


Reproductive / Genitalia / Genitourinary  

Not needed for this concern (chest pain)




Denies muscle weakness, neck or shoulder pain, and tremors




Denies numbness, tingling, loss of movement or sensation, vertigo




Denies anxiety, depression, suicidal or homicidal thoughts




Denies increased thirst, hunger, unexplained weight loss or gain,


Hematologic /Lymphatic


Denies hemoptysis, swollen nodes, and fever

Immune function  

Denies recurrent infections, use of immunosuppressants, and low blood cell counts





Physical Exam


Avoid describing findings as “normal”, “WNL”, “appropriate”, “intact”.  Instead describe what you found on evaluation

Episodic SOAP note should have 3-5 elements addressed in the pertinent body system

Comprehensive SOAP note should have 5-8 elements addressed in the pertinent body system




XX year old XXX female in no acute distress.  Speech clear and appropriately answers questions.  Good historian.


General description of patient including age, gender, nutritional status, habitus, attention to grooming, state of cooperativeness/demeanor, overall picture of wellness/distress


Vital Signs


Bp 135/74.  Pulse 82.  Respirations 20  Temp 98.7 orally.Pulse ox on room air is 97%  Height 66 inches.  Weight 227 lbs.  BMI 36.6


Temperature, Pulses (apical and radial), Respirations, BP (Postural PRN), Ht, Wt, BMI





Skin pink with rebound less than 2 seconds.  Capillary refill brisk in fingers bilaterally.Herpetic rash absent to chest, torso, abdomen, and flank.




Eyes:  PERRLA. 

Ears:  TM’s pearly gray bilaterally without effusion.  Light reflex @5 on right and @7 on left

Nose:  Nares patent bilaterally.  Turbinates pale without exudate or polyps.

Throat:  Pharynx without redness or irritation.  Dentition does not show erosions




Negative lymph node swelling at anterior and posterior cervical chains as well as infra and supraclavicular areas.




Chest is tender to palpation along 2nd to 5th costochondral joints at the sternum bilaterally.  The pain is reproducible with deep breath and when patients rotates chest.  Breath sounds are clear bilaterally and cough is not productive.  Chest is symmetrical with bilateral chest rise.  Chest percussion negative for consolidation.




Regular S1 and S2 without gallop or murmur.  PMI located midclavicular line at 5th ICS.  Radial and pedal pulses are 2+ bilaterally.  Negative homan’s sign bilaterally.  Peripheral edema absent bilateral lower extremities




Not needed




Abdomen soft, non-tender throughout.  Positive bowel sounds x4 quadrants.  Liver and spleen not palpable.  Negative rebound on light and deep palpation.

Female Genitourinary/


if applicable



Not needed


Male Genitourinary/

Prostate if applicable


Not needed




Not needed


Including frailty evaluation if applicable


Non-tender to palpation at cervical spine, bilateral clavicles, and shoulders.  Neck and shoulders with full active ROM.  Gait steady without imbalance




Alert, oriented to name, place, and date.  Deep tendon reflexes 2+ at radialis and Achilles. 



(Mental Status, Cranial nerves, Motor, Cerebellum, Motor, Cerebellum, Sensory, Reflexes)





Mood is pleasant.  Demonstrates insight as evidenced by verbalization that uncontrolled hypertension can cause her kidneys to fail.  Demonstrates judgement as evidenced by compliance with taking medications.


(Minimal documentation is mood, insight, and judgement. Document findings from depression screen, Mini-mental status exam, CAGE, etc.)


Diagnostic Information


2.10.19  EKG negative for ischemia, injury, and infarct

2.2.18 Cholesterol was 250


Results of diagnostic testing conducted at the time of the visit OR previously done and being used to support the diagnosis and management plan for the current visit







5 differential diagnoses

for each presenting problem

Data in your findings that support this diagnosis Data in your findings that rule out this diagnosis Citation of evidence for accepting or rejecting the diagnosis



sternal chest pain radiating across chest, pain is reproducible with inspiration, recent respiratory infection

Pain waxes and wanes

Meds:  Pain improves with NSAID


SH: smokes 1 pack per day



Chest pain diminishes when holding breath

Costal areas tender to touch, pain is reproducible with movement

CXR: negative for pneumonia, CHF

EKG: negative AMI


Presence of shortness of breath, absence of chest wall trauma,


PE:  Blood pressure is normal 135/74.

Lungs are clear , chest percussion negative for consolidation

Accepting Diagnosis because

Patient has costal tenderness which is 98% sensitive for inflammation as cause of pain (Blue et al, 2018)


Acute Myocardial infarction


sternal chest pain radiating across chest, shortness of breath


PMH: personal history of HTN,


FH:  family history of CAD, CVA,


SH: smokes 1 pack per day, does not exercise, eats fast foods daily


PE:  negative for …

Positive for ….

Dx:  cholesterol on Feb 2, 2018 was 250


Did not have diaphoresis, pain improves with NSAID


PMH:  BMI indicates healthy weight,  negative for CAD, AMI


PE:  Blood pressure is normal 135/74. tenderness across the anterior chest at costovertebral angles bilaterally, pain is reproducible with inspiration


Dx:  EKG negative for injury (ST changes), ischemia (change in T-wave), and infarct (Q wave changes)

Rejecting Diagnosis because:

Pain of angina and AMI typically is not reproducible nor does it improve with the use of NSAID.  EKG negative for findings of ischemia, injury, infarct.  (Smith et al, 2018)


sternal chest pain radiating across chest, gets worse when laying down


PMH: personal history of GERD


Meds:  Pepcid help to decrease chest pain


SH: smokes 1 pack per day, does not exercise, eats fast foods daily


PE:  negative for …

Positive for ….


Absence of heart burn, waterbrash, pain is not related to food intake, pain decreases with NSAID


PMH:  BMI indicates healthy weight,


PE:  Blood pressure is normal 135/74.

Pharynx without redness or irritation, dentition does not show erosion, abdomen soft, non-tender, positive bowel sounds

Rejecting Diagnosis because:

Absence of heartburn and waterbrash along with pain not related to food intake makes the likelihood of GERD diagnosis less than 10% according to Jones et al, 2018

Pneumonia HPI / ROS:

sternal chest pain radiating across chest, shortness of breath, pain is reproducible with inspiration, recent respiratory infection


SH: smokes 1 pack per day, does not exercise, eats fast foods daily




Negative for …


Positive for ….



Does not have fever, tachycardia, chills, malaise


PMH:  no history of immunosuppression


PE:  Blood pressure is normal 135/74.

Lungs are clear , chest percussion negative for consolidation

Dx:  EKG without is


Patient is not demonstrating S/S of acute infection including fever and chills and physical exam of lungs does not reveal congestion or consolidation. (Blue et al, 2018)

Pulmonary Emboli HPI / ROS:

sternal chest pain radiating across chest, shortness of breath,


PMH:  recent liposuction of abdomen last month


SH: smokes 1 pack per day, does not exercise, eats fast foods daily



Negative for …

Positive for ….


Pain decreases with NSAID use, does not have hemoptysis


PMH:  negative for coagulopathy


FH:  negative for coagulopathy


SH:  negative risk factors for clotting event – recent travel, use of OCP


PE:  Blood pressure is normal 135/74.

Lungs are clear , negative peripheral edema and homan’s sign bilaterally


Dx:  D-Dimer normal

Absence of risk factors for thrombosis, along with negative d-dimer decreases the likelihood of pulmonary emboli to less than 3%.  Pain of pulmonary emboli also does not respond to NSAID use

(Peter & Paul, 2016)







Final ICD 10 diagnosis codes for the current visit


ICD 10 Code Corresponding Diagnosis



Acute costochondritis


Primary diagnosis for the visit






Additional diagnoses for the visit AND active problems from the medical history that may contribute to the diagnosis and plan for the current visit (ie DMII or HTN may impact management even if the visit is not related to these diagnoses)







(For graded SOAP note submissions, include rationale for all components of treatment plan and support with citations from peer-reviewed information)







Additional Diagnostic tests needed  

Chest x-ray completed today in the office but will have to await radiology interpretation which takes 24 hours.  Chest x-ray is recommended for patients suspected of having costochondritis who are older than 35 years and/or have signs and symptoms of a coronary event (Author, Year)


include rationale with citation for each diagnostic test being ordered

Treatments: Pharmacological  

Celebrex 200mg 1 tablet by mouth twice a day.  NSAIDS work to decrease inflammation of the costochondral area (Author,year)


Tylenol Extra Strength 2 tablets by mouth every 6 hours as needed for pain.  Research shows Tylenol is effective for relief of mild to moderate pain (Author, year)


If there is not improvement in pain within 24-48 hours, will consider Medrol dose pak as stronger anti-inflammatory may be needed (Author,year)


Precipitating event is likely a viral URI and patient is no longer symptomatic.  Therefore anti-infectives are not indicated (Author, year)



include rationale with citation for each pharmacological treatment ordered





Continue to apply local heat for 10 minutes every 1-2 hours as needed to discomfort.  Heat increases blood flow and makes connective tissue more flexible which will decrease joint pain and reduce inflammation (Author, year)


Avoid unnecessary exercise or activities that make the symptoms worse such as reaching up, twisting the torso, or lifting objects.  Limited activity will allow inflammation to resolve (Author, year)


Return to normal activities when they are tolerated.  As inflammation decreases, normal day to day activities are less painful and should be resumed to avoid stiffness and loss of motion (Author, year)


include rationale with citation for each non-pharmacological treatment ordered


Patient Education


Provided handout on costochondritis including symptoms and treatment plan outlined above.  Educated patient on the side effects and adverse effects of Celebrex and Tylenol.


Rationale:  Empowering patients with knowledge on how to manage and improve their own health helps to engage the patient in self-care and encourages them to take responsibility for their health (Author, date)


nclude rationale with citation for patient education


Consultations recommended with



Referral to cardiology – Dr. Yam Lam – to continue evaluation of chest pain associated with shortness of breath.  Appointment is Tuesday June 30, 2019 at 11:15 am.


include rationale with citation for each consultation ordered.  Also include the name of the provider, area of specialty, and date/time of the appointment




Return to office in 5 days for follow-up to evaluate patient progress and effectiveness of medications (Author, year)


Next office visit scheduled, identify the plan for follow-up, note expectations for further treatment.








CPT Billing Codes Reflected in the Treatment Plan


CPT Code Corresponding Diagnosis


Office visit E/M code

Established office visit, expanded problem focused history, exam, and low complexity medical decision-making
2.   85004 Complete Blood Count
3.  93040


4.  71010 Chest X-ray, single view frontal


Point of care testing (urine dipstick, wet mount, x rays, etc.) and resulted IN OFFICE, and any procedures done in office






IM. A. FNP Student

South University

Savannah GA



Patient Name ______________X.X________________    Date ___Month/Date/Year_________



Celebrex 200mg capsules

Sig:  one capsule by mouth twice a day

Disp:  #30


No refills.



Refills: __0__



Signature ______Sallie Student, RN, NP Student________________________








Author, A.  (Year).  Title of journal article.  Title of Journal, volume (issue if paginated),

page ranges.  doi:

Author A.  (Year).  Title of journal article.  Title of Journal, volume, page ranges.


Author, A.  (Year).  Title of journal article.  Title of Journal, volume, pages ranges. 

Retrieved from URL for home page of journal.


Author, A. (Year). Title of book (edition).   E-book vendor.  Retrieved from URL


Author, A.  & Author, B.  (Year).  Title of chapter in a book.  In C. Author & D. Author (Eds.),

Title of Book (x edition).  Retrieved form URL for digital book.

BOOKS:  UP-TO-DATE (electronic edited book format)

Author, A., & Author, B.  (Year).  Title of article in the book.  In X. Y. Author (Ed.), UpToDate. 

Retrieved from


Author, A., & Author, B.  (Year).  Title of chapter in a book.  In C. Author & D. Author (Eds.),

Title of Book (x edition)(pages – pages).  City, State published:  Name of publisher.0

Author, A., & Author, B., (Year).  Title of book (edition).  City of Publication:  Publisher.


Topic.  (Year).  In Name of Encyclopedia or Dictionary.  City of Publication:  Publisher.

Topic.  (Year).  In Name of Encyclopedia or Dictionary.  Retrieved from….


Author, A.  (Year, Month Day).  Title of web page.  Website.  Retrieved from URL address


Author, A. (Year, Month, Day).  Title of Website.  Retrieved from URL address.

Author, A. (Year).  Name of chapter.  In X.X. XYZ (ed.), UpToDate.  Retrieved from URL address.


Title of webpage. (Year, Month, Day).  Retrieved from URL address.




SUBJECTIVE FINDINGS: Chief compliant, HPI 10
The patient’s explanation of what the problem is, in the form of a summarized narration. Allergies, Meds, PMH, Surgical Hx, Social Hx, Family Hx, and any relevant hx 10
ROS: Select the elements that are most pertinent to the patient’s concerns, yet meet clinical standards for best practice & diagnostic accuracy. Remember  to address the appropriate # of organ systems for the level of the service billed 10


Includes the info that’s collected from the pt’s current  health situation. Includes: ht, wt, vs & physical findings

Focused PE. You will only examine the systems that are pertinent to the CC, HPI and history. DO NOT use WNL or normal. You MUST describe what you see.

-Include results of point of care testing conducted at the time of the visit OR diagnostic testing previously done and being used to support the diagnosis & management plan for the current visit



This is a summary of the key symptoms & diagnosis of the pt. and a list of other likely diagnoses.

Include 3 differential and a final diagnosis. Make sure you identify how you ruled in/out a diagnosis using current evidence-based references within the past 5 years.

-Use correct ICD10 codes for final diagnosis.

-Final diagnosis may include any active medical problems being addressed in the patient education & treatment plan



Steps that the provider will take to treat the patient and their concerns

Identify diagnostics, prescriptions, referrals, patient education, patient disposition, follow up appointment.

-Use CPT billing codes for office visit (Level of service) and for testing conducted during the office visit.  Again, make sure you identify the rationale for your patient education and/or treatment plans using current evidence-based references within the past 5 years.

APA Format Use of correct APA 7th ed format including title page, reference page, correct grammar/spelling and proper citations 5


You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.
Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

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