Directions: Read over the SOAP note and formulate a primary diagnosis. Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.
- Upload a copy of your completed SOAP note.
- Upload a copy of the evaluation & management score sheet.
Case Study: A 3-year-old girl is brought to your office by her mother because she has a fever and complains that her right ear hurts. She has no significant medical history. The child is not pleased to be in the PCP’s office and has been crying. Her mother explains that she developed a “cold” about 3 days ago with sniffles. Her temperature is 37.8°C (100°F). Physical exam was completed with some difficulty because of the child’s irritability. The only abnormalities are slight redness of the throat, a nose full of thick green mucus, and injected tympanic membranes. She denies nausea, vomiting, diarrhea, headache, or change in urine output.