Assignment Criteria:Students will complete a Soap note and include the following:1. Subjective findingsa. Chief complaint (CC)b. History of present illness (HPI)i. Use mnemonic (when appropriate): onset, location/radiation, duration, character, aggravating factors, relievingfactors, timing, and severity (OLDCARTS) for acute symptomsii. Include pertinent positives and negativesc. Relevant past medical/surgical/social/family historyd. Medicationsi. Allergies, prescription/over the counter (OTC)/herbal medicationse. Relevant review of systems (ROS)
2. Objective findingsa. Appropriate physical examination based on subjective findingsb. Relevant positive and negative diagnostic testing including previous pertinent diagnostic tests related to visitc. Screening tools and positive and negative results
3. Assessmenta. Correct primary diagnosisb. Correct differential diagnoses
c. Correct ICD-10/Current Procedural Terminology (CPT) codes
4. Plana. Identify and orders correct diagnostics, prescriptions, referrals, and follow-up planb. Patient education relative to treatment plan.c. Correctly written out a prescription for one medication prescribed for the patient.i. If a medication not prescribed, write out a prescription for a medication that might be prescribed for a similar patient
5. Include two current evidence-based guidelines and/or peer-reviewed scholarly journals to support patient education andtreatment plan. The student can pick one evidence-based guideline and one scholarly article. References should be fromscholarly peer-reviewed journals (check Ulrich's Periodical Directory) and be less than five (5) years old.
6. APA format required (attention to spelling/grammar, a title page, a reference page, and in-text citations