Pick any ‘ADULT’ Acute or Chronic Disease? ?Must use the sample template for your soap note? ?Use APA format and must include minimum of 2 Scholarly

  

 Pick any “ADULT” Acute or Chronic Disease 
 Must use the sample template for your soap note 
 Use APA format and must include minimum of 2 Scholarly Citations. 
Check attached document

MRUMSN5600LSOAPNOTETemplate2021-13.docx

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(Student Name)

Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C

Soap Note # ____ Main Diagnosis ______________

PATIENT INFORMATION
Name:
Age:
Gender at Birth:
Gender Identity:
Source:
Allergies:
Current Medications:
·
PMH:
Immunizations:
Preventive Care:
Surgical History:
Family History:
Social History:
Sexual Orientation:
Nutrition History:

Subjective Data:
Chief Complaint:
Symptom analysis/HPI:
The patient is …

Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL:
NEUROLOGIC:
HEENT:
RESPIRATORY:
CARDIOVASCULAR:
GASTROINTESTINAL:
GENITOURINARY:
MUSCULOSKELETAL:
SKIN:

Objective Data:
VITAL SIGNS:

GENERAL APPREARANCE:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:

ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.
Differential diagnosis (minimum 3)
–
–
–
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
· –
· –
Pharmacological treatment:
–
Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)

Follow-ups/Referrals
References (in APA Style)
Examples
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
(25th ed.). Print (The 5-Minute Consult Series).

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