The goal of this assignment is to practice writing a SOAP Note for a sick or episodic visit related to the focus system(s) reviewed in the previous week’s learning materials. Review the SOAP Note Rubric. Use a case from the previous week’s discussion or patient from your video submission or clinical practicum experience (adding content as needed to represent abnormal findings). Submit your own note. Do not submit documentation from the patient’s record.
FOCUS assessment HEENT-NECK
CASE: Room 1: 2yo Richie is brought to the clinic by his mother Rachel Regis for nasal congestion and tugging at his left ear