4yr old male complaining of right ear pain. Dx: Ottis media 
Please use template attached; make up all information.
Problem-focused SOAP Note Format     
Demographic Data 
Age, and gender (must be HIPAA compliant) 
Subjective 
Chief Complaint (CC): A short statement about why they are there 
History of Present Illness (HPI):  Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym 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 

Family Hx: any history of CA, DM, HTN, MI, CVA?  
Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc. 
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy) 
Objective 

Vital Signs 
Physical findings listed by body systems, not paragraph form- Highlight abnormal findings 

Assessment (the diagnosis) 

At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each 
Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation 
Plan 
Dx Plan (lab, x-ray) 

Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any) 
Pt. Education, including specific medication teaching points 
Referral/Follow-up 
Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due
Subjective, Objective, Assessment, Plan (SOAP) Notes
Student name:
Patient name (initials only):
Ethnicity:
Course:
Date:
Age:
Time:
Sex:
SUBJECTIVE
CC:
HPI:
Medications:
Past medical history:
Allergies:
Birth hx: (use only on well child visits):
Immunizations:
Hospitalizations:
Past surgical history:
Social history:
Developmental Assessment: (include on well child visit only but may be necessary for problem
focused notes)
FAMILY HISTORY
Mother:
MGM:
MGF:
Father:
PGM:
PGF:
REVIEW OF SYSTEMS
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary/Gynecological:
Musculoskeletal:
Neurological:
Psychiatry:
OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for
well child exam)
Weight:
Height:
BMI:
BP:
Temp:
Pulse:
Resp:
General:
Skin:
Eyes:
Ears:
Nose/Mouth/Throat:
Breast: Heme/Lymph/Endo:
(Insert plotted growth chart below on all well child soap notes)
General appearance:
Skin:
HEENT:
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Labs performed in office the day of visit:
Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or
ruled out)
Differential diagnoses:
Diagnosis (ICD 10 code and reference):
1. Diagnosis, (ICD 10 code and reference):
2. Diagnosis, (ICD 10 code and reference):
3. Diagnosis (ICD 10 code and reference):
Plan/therapeutics/diagnostics;
Education provided:
CPT Code:
Anticipatory guidance (well child visit only)
References: