8. SOAP Progress Note:

Subjective:Patient is brought in by mother for drainage in both ears for 2 days.Minimal cough.Mild runny nose and congestion.No vomiting or diarrheaa.No sore throat that mother is aware of.Eating and drinking normally.No skin rash.Immunizations are up to date.

• Objective:Alert and appropriate for age.No acute distress.Cries on exam.Conjunctive normal.Tympanic membranes dull and red.Loss of landmarks on the left with marked bulging.Pharynx is negative.Lungs are clear.Heart is regular rate and rhythm.Vital signs were stable.
• Assessment:Bilateral otitis media.
• Plan:Zithromax 100 mg/5mL, use as directed.Recheck the ears in 10 days.Return to clinic sooner if worse.

What key documentation element is missing from this SOAP note?

• History of Present Illness
• Review of Systems
• Chief Complaint
• Social History

9. Reference the SOAP note ABOVE (8)

What key element controls the section for medical decision making?

• General appearance
• Age of patient
• Prescribed medications
• Follow-up treatment