Sally is a 22-year-old female who recently became bothered by a rash that is itchy, red, inflamed, and dry. She also has scaly areas that she says are getting worse. The rash is only around her umbilicus and on her elbows. Both of her parents have psoriasis, but she doesn’t believe this is the problem, because it appears to be different from her parents’ lesions. She is living in Florida, is under a lot of stress in high school, and just recovered from a lingering upper respiratory infection (URI).
Problem-focused SOAP Note Format Demographic Data · Age, and gender (must be HIPAA compliant)
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: