MN605 Discussion 5

Documentation SOAP Note

Create a focused exam SOAP note based on a case during your clinicals. This same case will be used for your Unit 6 presentation video. References should be guidelines that support the treatment plan and related condition/s.


  • Opener presentation of the patient (age/sex/presentation of issue with key past DX)
  • History of present illness (HPI) (OldCarts)
  • Other related past medical history
  • Review of systems (ROS)


  • Vital signs and physical exam on pertinent body systems


  • Assessment including differentials and specific labs or X-rays reviewed


  • Explain the plan that you are suggesting or that was done, including any education, further work-up, specific medications with doses and frequency, consultations/referral, and follow-up.
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