Posted: September 18th, 2023

Mini-SOAP note Chief Complaint (CC): Burning sensation while urinating

Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit here as a Word Document. See the example template below for the required format.

Patient seen is a 53 y/o female complaining of burning sensation while urinating.

Dx: UTI

please complete the mini SOAP below.

Problem-Focused SOAP Note Format

Demographic Data

Age, and gender (must be HIPAA compliant)
Subjective

Chief Complaint (CC) unless an Annual Physical Exam (APE)
History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)
Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance as applicable
Family Hx: As applicable
Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
Objective

Vital signs
Physical findings listed by body systems, not paragraph form
Assessment (Diagnosis/ICD10 Code)

Include all diagnoses that apply for this visit
Plan

Dx Plan (lab, x-ray)
Tx Plan: (meds)
Pt. Education, including specific medication teaching points
Referral/Follow-up
Health maintenance (including when screenings, immunizations, etc., are next due):

A mini-SOAP note for the 53-year-old female patient complaining of burning sensation while urinating:
Demographic Data:
53-year-old female
Subjective:
Chief Complaint (CC): Burning sensation while urinating
History of Present Illness (HPI): Patient reports experiencing burning pain with urination for the past 2 days. The burning is constant and worsens with urination. She denies any other symptoms.
Past Medical History (PMH): Hypertension, diabetes
Family History (FH): Mother with history of breast cancer
Social History (SH): Married, retired teacher. Does not smoke or drink.
Objective:
Vital Signs: Temp 98.6 F, BP 140/90, Pulse 80, Respirations 18

Physical Exam: General exam unremarkable. Abdomen soft, non-tender. Normal female genitalia on exam.
Assessment:
Urinary tract infection (UTI) (N39.0)
Plan:
Diagnostic Plan: Urinalysis, urine culture and sensitivity
Treatment Plan: Ciprofloxacin 500mg PO BID for 7 days.

Patient Education: Importance of taking all antibiotics as prescribed. Drink plenty of water and cranberry juice. Call if symptoms worsen or do not improve in 2-3 days.
Return in 2 weeks for recheck or sooner if symptoms persist.
References:
Centers for Disease Control and Prevention. (2022, May 18). Urinary tract infection (UTI) statistics. https://www.cdc.gov/nchs/fastats/urinary-tract-infections.htm
Mayo Clinic. (2022, June 11). Urinary tract infections (UTIs) in adults. https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447
MedlinePlus. (2022, June 7). Urinary tract infection. https://medlineplus.gov/urinarytractinfections.html
National Kidney Foundation. (2020). Urinary tract infections in adults. https://www.kidney.org/atoz/content/urinary-tract-infections-adults