Author name
Institutional affiliation
Course number and name
Instructor name
Assignment due date
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, SOAP NOTE
Gomez Juan, Alejandro
Miami Regional University
Date Encountered: 6/13/2024
Preceptor/Clinical Site: ANIA MEDICAL CENTER INC / PEREZ, ANIA
Clinical Instructor: [Clinical Instructor's Name]
Soap Note # Urinary Tract Infection (UTI)
PATIENT INFORMATION
Name: C.F
Age: 14 years
Sex: Female
Source: Patient
Allergies: None reported
Current Medications: None
PMHX: There is no significant past medical history
FAMHX: There is no family history of UTI that has been reported
SOCHX: The patient currently lives in a rural area. She is a student and attends school. She do
participate in sports activities.
SUBJECTIVE DATA
Chief Complaint: pain with urination
Symptom analysis/HPI: According to the case, a 14-year-old male of African American
descent presents to the clinic or healthcare facility for a follow-up visit. Based on her chief
complaint, she reports ongoing pain and discomfort with her urination. According to her