Hey ChatGPT! Write a SOAP note for a healthy adult with a normal exam and no medical problems. Include the ICD code with the Assessment and Plan.

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SOAP Note – Healthy Adult, Annual Exam

S – Subjective

• Chief Complaint: Routine physical exam.
• History of Present Illness: Patient presents for annual preventive visit. Reports feeling well with no current complaints. Denies chest pain, shortness of breath, palpitations, dizziness, headache, abdominal pain, nausea, vomiting, bowel/bladder changes, fevers, chills, or unintentional weight changes. Normal energy level, sleep, and appetite.
• Past Medical History: None.
• Past Surgical History: None.
• Medications: None.
• Allergies: NKDA.
• Family History: Non-contributory.
• Social History: Non-smoker. Denies alcohol or drug use. Balanced diet, regular exercise. Occupation: [insert]. Living situation: [insert].

Review of Systems (ROS):

• Constitutional: No fever, chills, weight change, or fatigue.
• HEENT: No vision/hearing changes, congestion, sore throat, or ear pain.
• Cardiac: No chest pain, palpitations, edema.
• Respiratory: No cough, wheezing, or shortness of breath.
• GI: No nausea, vomiting, abdominal pain, diarrhea, or constipation.
• GU: No dysuria, hematuria, frequency, or urgency.
• MSK: No joint pain, stiffness, swelling, or weakness.
• Neuro: No headache, dizziness, syncope, weakness, or numbness.
• Psych: No anxiety, depression, or mood changes.
• Skin: No rashes, lesions, or pruritus.

O – Objective

• General: Well-appearing, no acute distress.
• Vital Signs: Within normal limits.
• HEENT: Normocephalic, atraumatic. PERRLA, EOMI. TMs clear. Oropharynx without erythema or exudate.
• Neck: Supple, no lymphadenopathy.
• Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops. Pulses intact.
• Respiratory: Lungs clear to auscultation bilaterally. No wheezes, rales, or rhonchi. Normal effort.
• Abdomen: Soft, non-tender. Bowel sounds normative. No masses.
• MSK: Normal strength and range of motion. No deformities.
• Neuro: Alert and oriented x3. Cranial nerves II–XII grossly intact by observation. Motor/sensory intact. Reflexes symmetric.
• Skin: Warm, dry, intact. No rashes or lesions.

A – Assessment

• Z00.00 – Encounter for general adult medical examination without abnormal findings

Healthy adult. No acute medical concerns. Preventive health maintenance visit.

P – Plan

• Continue healthy diet, regular physical activity, hydration, and adequate sleep.
• Encourage routine dental and eye exams.
• Preventive screenings discussed and ordered as appropriate (lipids, colorectal, cervical, mammogram).
• Immunizations reviewed and updated as needed.
• Patient education on lifestyle, stress management, and wellness.
• Follow up annually or sooner if concerns arise.