Patient: 26 year-old female came into the office for her yearly physical with a diagnosis of cystitis
******Please use OLDCARTS for the history of the present illness*****
answer everything and remove all instructions on the template
ADD IN COMPLETED DIPSTICK WITH RESULTS
SOAP NOTE TEMPLATE (Well Exam/Comprehensive Visit)
Student Name: Date: Course:
Patient Demographics: (age, gender, ethnicity, etc.)
Chief Complaint: ??quote patient?
History of Present illness: 7 attributes required
______________________________________________________________________________
(For patients who are Newborns, Infants, Toddlers, or School Age)
Birth History:
Nutrition:
Elimination:
Activity:
Sleep:
Safety:
Developmental Milestones:
(For patients who are Adolescents)
HEADSSS Assessment: BRIEFLY summarize your assessment here and elaborate on any abnormal findings
______________________________________________________________________________
Past Childhood Illnesses: measles, mumps, rubella, varicella, scarlet fever, rheumatic fever, polio, and any other childhood illnesses such as Asthma
PMH: dates in reverse chronological order.
PSH: surgery dates in reverse chronological order.
Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies
Untoward Medication Reactions: include type of reaction/severity/date
Immunization Status: e.g. Flu, Prevnar 13, TdaP, etc.
Date must be included
Screenings: e.g. Newborn screening, vision screening, dental visits, TB screening/PPD, etc?¦
(Indicate if results were normal or abnormal)
FMH: include relevant genetic risk history for living/deceased immediate relatives including grandparents, parents, siblings, children, grandchildren; for deceased relatives include cause of death and age; for sick relatives include age of onset
Personal History/Social History: family relationship status, children, occupation, living arrangements, exercise, personal interests, religion, illicit drug use, tobacco-use in pack years, if stopped smoking for how long did they smoke and when did they quit smoking; alcohol use??how many drinks/week, type of alcohol
Females: LMP and relevant OB/GYN history Gravida, Para, Abortions-spontaneous vs. induced
age of menarche, duration of period, avg. length of cycles, flow, etc.
Sexual History: #of partners, sex of partner/s, protected/unprotected sexual relations, contraception
Current Medications/OTCs/Supplements: indicate Dose, Route, Frequency (write class of medication in parentheses):
For Comprehensive Visit, document a full ROS/PE
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