AHA EENT 3.3 SOAP Note.docx - S.O.A.P Note Assignment 3.3...

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S.O.A.P. Note: Assignment 3.3 EENT Documentation CASE ID# S ubjective O bjective A ssessment (diagnosis [primary and differential diagnosis]) P lan (treatment, education, and follow up plan) Chief mplaint What brought you here today…(e.g. headache) Nasal congestion History of Present Illness Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form Onset 2 Weeks ago Frontal Sinus and maxillary sinus tenderness, headache, congestion 2 weeks Pressure, foul smelling Tylenol for headache, Sudafed not working Coughing and sore throat at night, ear pain, fatigue Moderate Location Duration Character Aggravating/associated factors Relieving factors Temporal factors – other things going on Severity Past Medical History Adult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current medications Allergies: Aspirin, seasonal Frequent sinus infections-3 in the last 6 months, antibiotics 3 months ago, Nasal polyps removed by ENT MD 5 years ago then steroid shots

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