MINI SOAP NOTE: WELLNESS EXAMINATION
Patient initial (one initial only), 8 age, and Female gender must be HIPAA compliant
Chief Complaint (CC)
History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)
Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance as applicable
Family Hx: As applicable
Social Hx: Including nutrition, exercise, substance use, school, etc.
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, vaccines)
Physical findings listed by body systems, not paragraph form
Assessment (Diagnosis/ICD10 Code)
Include all diagnoses that apply for this visit
Dx Plan (lab, x-ray)
Tx Plan: (meds)
Pt. Education, including specific medication teaching points Referral/Follow-up
Health maintenance (including when screenings, immunizations, etc., are next due):
*based on population focus, some additional details may be required by faculty Health maintenance: USPSTF
(Also add the recommendations by USPSTF)
MINI SOAP NOTE: WELLNESS EXAMINATION Demographic Data Patient initial (one ini
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MINI SOAP NOTE: WELLNESS EXAMINATION
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