To do a comment to the post below in APA style with citation, needs 2 credible reference from 2013 and above.
Episodic/Focused SOAP Note Template
J, 11, Male, XX (Race)
CC: “Mild ear ache”
HPI: The patient is 11 year old XX male who presented himself with a mild right ear ache, which started two days ago. Associated symptom include possible fever, right ear pain, difficulty hearing from the right ear. Associated symptom are exacerbated with sleep.
Current Medications: Inquire if patient is currently taking any medications, rule out earring loss related to medication toxicity.
Allergies: Inquire about allergies.
PMH: Inquire if patient has a history of acute otitis media or underlying hearing loss. Inquire if patient has had tonsillectomy or an adenoidectomy in the past.
SH: Spends time in pool during summer.
FH: Inquire if family members have history of hearing loss.
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