Comprehensive Diagnosis & Treatment Plan (CDTP) (SOAP) For 5yo Female with Allergic rhinitis, Acute Nasopharyngitis
Directions: Label each section of the Comprehensive Diagnosis & Treatment Plan
(CDTP) (SOAP), each body part and system. Do not use unnecessary words or
complete sentences. Use only approved medical abbreviations (S=subjective;
CC=chief complaint; etc). See topic outline for the 5 assigned populations.
Title: Student name, CDTP #1-5, population: Example: J. Smith, CDTP #1, Peds
S: Subjective Data
CC: A statement describing the symptom, problem, condition, diagnosis, or other reason for
visit. Use quotes (pts own words) in this section.
HPI: (History of present illness) A chronological description of the development of the
patient’s present illness from the first sign or symptom or from the previous encounter to
the present. Symptom analysis 7 Variables: location, quality, severity, duration, timing,
modifying factors, associated signs and symptoms. Or an update on health status from
the past year or last visit.
PMH: Update current medications, allergies, prior child and adult illnesses and injuries,
operations and hospitalizations allergies, age-appropriate immunization status. LMP.
PSH (Surgical History) list dates and surgeries and reasons for surgery if significant
(cancer).
FH: (Family History) Update significant medical information about the patient’s family
(parents, siblings, and children). Include specific diseases related to problems identified
in CC, HPI or ROS.
SH: (Social History) An age-appropriate review of significant activities that may include
information such as marital status, living arrangements, occupation or grade in school,
history of use of drugs, alcohol or tobacco, extent of education and sexual history.
ROS: (Review of Systems). There are 14 systems for review. List positive findings and
pertinent negatives in systems directly related to the systems identified in the CC and
symptoms which have occurred since last visit; (1) constitutional symptoms (e.g., fever,
weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5)
respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9) integumentary
(skin and/or breast), (10) neurologic, (11) psychiatric, (12) endocrine, (13)
hematologic/lymphatic, {14) allergic/immunologic and no need to repeat information if
provided in the HPI.
0: Objective Data.
Vital signs: BP; HR; RR; Ht; Wt; BMI, pain, LMP. Head, chest, length if appropriate. Age or
population specific findings. Sufficient physical exam should be performed to evaluate areas
suggested by the history and patient’s progress since last visit. Document specific abnormal and
relevant negative findings. Abnormal or unexpected findings should be described. “Negative” or
“Normal” findings should be noted if related to body areas or findings not relevant to the
patient’s problem. Don’t use “normal”; “WNL” or “expected findings” be descriptive with your
physical findings. Record observations for the following systems (there are 12 systems for
examination), if they were examined: Constitutional (e.g. VS, general appearance), Eyes,
ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurologic,
Psychiatric, Hematologic/lymphatic/immunologic. Always document CV & Resp findings.
(CV: S1S2 without murmur, rub, gallop. Resp: BBS without adventitious sounds; = chest
expansion;
A: Assessment and Diagnosis
List and number the diagnoses (problems) in the following areas if applicable:
1. Health maintenance, 2. Acute self-limiting problems, 3. Chronic health problems
List Diagnoses (use medical terminology) & document ICD-9 code and a minimum
of 3
Differential Diagnoses for each diagnosis listed. 1. Chronic Sinusitis (473) DD: URI;
Pharyngitis; Allergic Rhinitis
P: Plan
List actions planned to manage each problem. Number the actions to correlate with the
problems in the assessment. Include diagnostic, therapeutic, and patient education actions.
Anticipatory Guidance, health promotion, disease prevention for the patient, family and
caregiver.
Follow-up should be specified with time or circumstances of return as PRN.
Prescriptions: provide all details for the order. EX: Amoxil 500 mg three time a day for 10
days Disp thirty (30), no refills. Include education: take with food, take all of medication even
though you may feel better, stop medicine & notify office if rash, SOB, N,V, diarrhea
occurs. Be specific about the education provided, not simply “explained medication”.
Provide APA 7th edition references for your assessment and plan. Do not use references older than 5 years.