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Using what you learned in both the HPI/ROS/PE lectures, try your hand at these two examples. You are expected to do a full SOAP note! The Assessment/Plan sections are pretty straight forward. Both scenarios are video-based and you’ll need to practice taking notes in real time.
Use the template to the file below to organize your note (or create something that works best for you). Delete entries as needed to accommodate your clinical scenario. Do not leave things blank.
Full H&P Practice SOAP Note Template.docxLinks to an external site.
IMPORTANT: IF YOU ARE UNFAMILIAR WITH A TERM, PLEASE LOOK IT UP! In the beginning, there will be LOTS of terms you lost with but the process of writing them out will help you learn them. Also, be careful with acronyms. Do not make them up. Make sure they agree with the industry standard, you can check
VIDEO 1
VIDEO 2
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