Template for the Soap

SUBJECTIVE: (15 points)

Chief complaint “2-3 words” (1 point)

Cough and trouble breathing.

OLDCART including pertinent positives and pertinent negatives (10 points)

Onset; The symptoms started two weeks ago.

Location; Lungs and throat as she is coughing and having trouble breathing.

Duration; Two weeks.

Characteristic; Moderate cough and difficulty breathing with a wheezing sound.

Aggravating factor(s); Walking and movement at night.

Relieving factor(s); None.

Timing; Difficulty breathing gets worse at night and patient feels short of breath after a cough.

Severity; Cough is moderate while breathing is worse.

Pertinent positive; Cough and shortness of breath.

Pertinent negative; No sputum seen, Sinus issues, congestion or chest pains.

Allergies: (1 points)

No known Allergy.

PMhx: (1 points)

No history of hospitalization.

Famhx: (1 Points)

No significant family history, all family members are healthy.

Current Meds: (1 points)

Haven’t tried cough medicine or anything yet.

OBJECTIVE: (15 Points)

*VS: (1 Point)

• - Complete the Physical Exam (10 Points). Only include pertinent systems, plus CARD and PULM)

General: The patient states that she doesn't feel good, and having active distress was noted.

HEENT: Neck: Denies head trauma and blurred vision. No conjunctivitis. Denies hearing problems, ear pain, or eye or ear discharge. Denies sinus problems, runny nose, and nasal congestion. Denies difficulty swallowing and sore throat.

Cardiovascular: Denies chest pain, feeling tight or heavy, discomforts, or edema. Denies history of murmur, fainting.

Respiratory: Cough and shortness of breath but denies sputum.

Gastrointestinal: Denies nausea, vomiting, weight loss or gain, constipation or diarrhea, no abdominal pain or blood in stool.

Genitourinary: Denies urinary frequency during the day and night, dysuria, burning sensation of urination, and hematuria.

Musculoskeletal/ osteopathic structure examination: Denies weakness, tenderness or spasm, rigidity—normal bulk tone.

Neurologic: Denies numbness, tingling, dizziness, vertigo, and a history of seizures.

Psychiatric: Denies mood change.

Endocrine: Denies polyuria and polydipsia, as well as heat and cold intolerance. Denies history of diabetes, adrenal or thyroid dysfunction.

*Diagnostic Test/labs/screening tools: (4 points) There may no test/ screening tool or just 2-3

 Pulse oximetry: 93% on room air.

Consider Chest X-ray if no improvement.

Spirometry if asthma suspected.

ASSESSMENT: (15 points)

*What is the primary Dx w/ICD 10 code (2 points)

 Asthma, Unspecified (ICD-10: J45.909)

*What is you rational for this dx. You must discuss pertinent findings and support your dx w evidence based literature (4 points) 

 Persistent cough and shortness of breath for 2 weeks

Worsening symptoms with activity and nighttime

History of exposure to a new pet (possible allergen)

Mild increased respiratory effort on examination

*Discuss 3 DDX w/ ICD code and rational—> primary dx does not count as a ddx

i. DDX#1 w ICD code and rational (3 points)

Upper Respiratory Tract Infection (ICD-10: J06.9) – Viral etiology could contribute, but duration and nighttime worsening suggest otherwise

ii. DDX#2 w ICD code and rational (3 points)

Allergic Rhinitis (ICD-10: J30.9) – History of exposure to new pet, but no nasal congestion or eye involvement

iii. DDX#3 w ICD code and rational (3 points)

 Pneumonia (ICD-10: J18.9) – Less likely due to absence of fever, crackles, and significant sputum production

Medication: MUST be written as a prescription and include home meds, OTC, etc

(10 points)

Med: Amoxicillin 400mg/5ml

Sig: Take 2 teaspoons po BID x 10 days

Disp: 120ml bottle (strawberry flavor). No refills

• Patient Name: [Patient’s Name]
• Date: [Date]
• DOB: [Patient’s Date of Birth]
• Medication: Amoxicillin 400mg/5ml
• Sig: Take 2 teaspoons (10 mL) by mouth twice daily for 10 days
• Dispense: 120 mL bottle (Strawberry flavor)
• Refills: None
• Home Medications:
  • Lisinopril 10mg – Take one tablet by mouth once daily for blood pressure
  • Metformin 500mg – Take one tablet by mouth twice daily for diabetes
• Over-the-Counter Medications:
  • Acetaminophen 500mg – Take one tablet every 6 hours as needed for pain or fever
  • Loratadine 10mg – Take one tablet daily for allergies
• Prescriber Name: [Doctor’s Name]
• DEA Number: [DEA Number]
• NPI: [NPI Number]
• Signature: __________________________

PLAN (20 points)

Tell me what you did w/ this child, your plan/ interventions to treat this child:

*Intervention(s)/ treatment(s) in office: (02, sutures, teach to use crutches, Tylenol, nebulizer etc.) (4 Points)

 Albuterol Nebulizer Trial:

• Administered in-office to assess response to bronchodilation.
• If improvement is observed, asthma is more likely.
• Monitor SpO2 and respiratory effort before and after treatment.

Education on Proper Breathing Techniques:

• Teach pursed-lip breathing to manage shortness of breath.
• Encourage controlled breathing to reduce anxiety-related hyperventilation.

Prescription Initiation (If Necessary):

• Pleșca et al. (2024) emphasizes on considering starting a short-term course of inhaled corticosteroids (ICS) if symptoms are persistent.

Monitoring and Observation:

• The patient was observed post-treatment for any adverse effects or lack of improvement.
• If no improvement is seen, escalation of care may be required.

*Screening tool(s) used (1 Point)

 Asthma Control Test (ACT).

*Referral(s) w rational (1 point)

 Pulmonology if symptoms persist beyond treatment.

*Address modifiable risk factor(s): eg stop smoking, reduce screen time, etc (2 points)

 Recommend limiting exposure to pet in sleeping area.

Keep warm at night.

PATIENT EDUCATION: (5 points) SPECIFIC TO THE DIAGNOSIS

Educate parent and patient about today’s visit e.g.  diagnosis, meds, expectations, outcomes: be aware of CANNOT MISS education like black box warnings Rx, etc.

#1 (1 point)

 Educate on asthma triggers and avoidance.

#2 (1 point)

Proper use of inhaler and nebulizer (if prescribed).

#3 (1 point)

According to Society & Chinese Medical Association (2025), both the parent and the patient should be educated on the importance of medication adherence.

#4 (1 point)

When to seek emergency care.

#5 (1 point)

 Follow-up instructions.

SDOH. (3 points) MUST USE HEADINGS

i. Economic stability (.5 points)

Family has stable income and access to healthcare.

No concerns about affording medications or follow-up care.

Parents have health insurance coverage for the child.

No reported financial barriers to accessing specialists if needed.

Transportation to medical appointments is not an issue.

ii. Neighborhood and physical environment (.5 points)

Exposure to a new pet (puppy) may be a contributing factor to respiratory symptoms.

Parents advised to limit pet exposure in the sleeping area and monitor symptoms.

Home environment is free of smoke exposure.

No concerns about housing stability or environmental hazards.

Family has access to clean air and ventilation in the home.

iii. Education (.5 points)

Parents are aware of the diagnosis and treatment plan.

They demonstrated understanding of how to use a nebulizer/inhaler if prescribed.

Parents can read and follow prescription instructions.

Child is attending school with no reported learning difficulties.

Family understands the importance of follow-up visits and symptom monitoring.

iv. Food (.5 points)

No concerns regarding adequate nutrition or access to healthy food.

No signs of malnutrition or undernourishment.

Parents report having access to grocery stores and fresh produce.

No dependence on food assistance programs.

Child’s weight is appropriate for age and height.

v. Community and Social context (.5 points)

Supportive family environment noted.

No concerns about social isolation or lack of care.

Child has a stable home with involved caregivers.

Family is involved in community activities or religious groups.

No history of domestic violence or unsafe living conditions.

vi. Health Care System (.5 points)

 Family has access to a primary care provider.

No barriers to obtaining prescribed medications.

Parents understand how to navigate the healthcare system.

Health insurance coverage is adequate for needed treatments.

No history of missed medical appointments due to system-related barriers.

Health Promotion/ Anticipatory guidelines (4 points)

THIS IS NOT EDUCATION. LOOK AT WHO, CDC OR BRIGHT FUTURES. Must be to age appropriate and specific especially when rec vaccinations, diets, activity etc

#1 (1 point)

Encourage flu vaccination.

#2 (1 point)

Reinforce hand hygiene and infection prevention.

#3 (1 point)

 Promote physical activity within limits.

#4 (1 point)

Provide guidance on proper sleep hygiene.

 Follow up: (5 points) 

Timing/ when & why: (1 points)

 Follow up in 1 week or sooner if symptoms worsen.

Next WCV (1 point)

 As scheduled.

*Symptom to watch for that will prompt an urgent return (red flags)> (3 points) Cannot be the same as education

#1 (1 point)

Increased difficulty breathing.

#2 (1 point)

Persistent wheezing or respiratory distress.

#3 (1 point)

SpO2 below 92%.

 OFFICE BILLING CODE and CPT CODES: (5 points)

Office visit: (1 point)

 Level 3 pediatric visit.

CPT CODES (4 points) There may be less or more than 4. Write all

99213 (Office Visit), 94640 (Nebulizer Treatment).

Clinical Guidelines (5 points)

*Name of guidelines (1 points)

 Global Initiative for Asthma (GINA)

*What does the guidelines tell you to do, or how to make a diagnosis (4 points)

(You need four facts to score 4 points)

 Assess asthma control and severity.

Aziz et al. (2024) advises use of short-acting beta-agonists (SABA) as needed.

Consider inhaled corticosteroids if persistent symptoms.

Educate parents on asthma action plan.