Last Name Q-Z Case Study 3: Focused Ear Exam
Amy, a 3 year old girl is brought to your office by her mother because she
has a fever and complains that her ear hurts. She has no significant medical
history. The child is not pleased to be in the provider's office and has been
crying. Her mother explains that she developed a “cold” about 3 days ago
with sniffles. As she cries she continues to cough and has yellowish nasal
discharge.
Episodic/Focused SOAP Note Template
Patient Information:
AM, 3-year-old , Female,
Hispanic S.
CC: “Ear Pain”
HPI: This is the symptom analysis section of your note. Thorough
documentation in this section is essential for patient care, coding, and billing
analysis. Paint a picture of what is wrong with the patient. Use LOCATES
Mnemonic to complete your HPI. You need to start EVERY HPI with age, race,
and gender (e.g., 34-year-old AA male). You must include the seven
attributes of each principal symptom in paragraph form not a list. If the CC
was “headache”, the LOCATES for the HPI might look like the following
example:
Location: ear
Onset: 3 days ago
Character: cries in pain
Associated signs and symptoms: fever, cough with yellowish discharge
Timing: after development of a cold
Exacerbating/ relieving factors: coughing, has tried taking tylenol, but it is
not effective
Severity: 10/10 on the Wong-Baker Faces pain scale
Current Medications: include dosage, frequency, length of time used and
reason for use; also include OTC or homeopathic products.
Last Name Q-Z Case Study 3: Focused Ear Exam
Amy, a 3 year old girl is brought to your office by her mother because she
has a fever and complains that her ear hurts. She has no significant medical
history. The child is not pleased to be in the provider's office and has been
crying. Her mother explains that she developed a “cold” about 3 days ago
with sniffles. As she cries she continues to cough and has yellowish nasal
discharge.
Episodic/Focused SOAP Note Template
Patient Information:
AM, 3-year-old , Female,
Hispanic S.
CC: “Ear Pain”
HPI: This is the symptom analysis section of your note. Thorough
documentation in this section is essential for patient care, coding, and billing
analysis. Paint a picture of what is wrong with the patient. Use LOCATES
Mnemonic to complete your HPI. You need to start EVERY HPI with age, race,
and gender (e.g., 34-year-old AA male). You must include the seven
attributes of each principal symptom in paragraph form not a list. If the CC
was “headache”, the LOCATES for the HPI might look like the following
example:
Location: ear
Onset: 3 days ago
Character: cries in pain
Associated signs and symptoms: fever, cough with yellowish discharge
Timing: after development of a cold
Exacerbating/ relieving factors: coughing, has tried taking tylenol, but it is
not effective
Severity: 10/10 on the Wong-Baker Faces pain scale
Current Medications: include dosage, frequency, length of time used and
reason for use; also include OTC or homeopathic products.
Last Name Q-Z Case Study 3: Focused Ear Exam
