Please follow the example provided for the outline and requirements for the soap note…
Patient ID:
Patient Initials: B.E Age: 15 Gender: M
Date of Birth: 00.00.00 Ethnicity: Hispanic
Patient Accompanied by: Mother
Is Patient/Guardian/Etc. A Reliable Historian: yes
New or Existing Patient: New
SUBJECTIVE:
Chief Complaint: “Wellness annual physical exam”
HPI: Introduction, OLDSCART Paragraph format, associated symptoms, paint the picture.
Past Medical History: 15-year-old Hispanic male presents to clinic today for his annual
wellness visit. Patient is new to this clinic. Patient presents with his mother. They recently moved
from a nearby city. He has made friends and has adjusted to his new school without much
difficulty. He plays soccer and has joined his high school team. Mother reports her son has had
good overall health and has never needed any continuous medication attention. She is requesting
a local podiatry referral for replacement insoles. She reports her son was seeing a podiatrist for
his flat fleet and he was given special insoles for his shoes. Mother reports they would like a
referral since they have moved and his old podiatrist is to far now.
Medical History
Surgeries: none
Hospitalizations: none
Allergies: none
Medication: Not currently taking any medications
Immunizations: up to date o