(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). Nutrition and Diet. Semester: Spring Course: MSN6150C Advanced Practice Pediatrics Preceptor:  REYES-CHOUZA, CARLOS  Clinical Site: IDEAL MEDICAL CENTER Setting Type: Patient Demographics Age: 12 years Race: Black or African American Gender: Male Insurance: Medicaid Referral: No referral Clinical Information Time with Patient: 25 minutes Consult with Preceptor: 15 minutes Type of Decision-Making: Moderate complexity Reason for Visit: New Consult Chief Complaint: Felling pressure behaving my eyes Type of HP: Detailed Social Problems Addressed: Sanitation/Hygiene Emotional Prevention   Procedures/Skills (Observed/Assisted/Performed) Physical Assessment - Physical Assessment (Perf) General Skills - Vital Signs (Perf) ICD-10 Diagnosis Codes #1 - J01.10 - ACUTE FRONTAL SINUSITIS, UNSPECIFIED CPT Billing Codes #1 - 99214 - OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; MODERATE LEVEL MED DECISION; 30-39 MIN Birth & Delivery Medications # OTC Drugs taken regularly: 0 # Prescriptions currently pre ...

1. (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,

2. 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)
-
-

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).
Nutrition and Diet.
Semester:
Spring
Course:
MSN6150C Advanced Practice Pediatrics
Preceptor:
REYES-CHOUZA, CARLOS
Clinical Site:
IDEAL MEDICAL CENTER
Setting Type:
Patient Demographics
Age:

4. 12 years
Race:
Black or African American
Gender:
Male
Insurance:
Medicaid
Referral:
No referral
Clinical Information
Time with Patient:
25 minutes
Consult with Preceptor:
15 minutes
Type of Decision-Making:
Moderate complexity
Reason for Visit:
New Consult
Chief Complaint:
Felling pressure behaving my eyes
Type of HP:
Detailed
Social Problems Addressed:
Sanitation/Hygiene
Emotional
Prevention
Procedures/Skills (Observed/Assisted/Performed)
Physical Assessment - Physical Assessment (Perf)
General Skills - Vital Signs (Perf)
ICD-10 Diagnosis Codes
#1 -
J01.10 - ACUTE FRONTAL SINUSITIS, UNSPECIFIED

5. CPT Billing Codes
#1 -
99214 - OFFICE/OP VISIT, EST PT, MEDICALLY
APPROPRIATE HX/EXAM; MODERATE LEVEL MED
DECISION; 30-39 MIN
Birth & Delivery
Medications
# OTC Drugs taken regularly:
0
# Prescriptions currently prescribed:
0
# New/Refilled Prescriptions This Visit:
2
Types of New/Refilled Prescriptions This Visit:
Analgesic/Antipyretic - NSAIDS
Infectious Diseases - Penicillins
Adherence Issues with Medications:
Knowledge deficit
Other Questions About This Case
Patient's Primary Language:
English
Smoking Assessment:
Never
Advanced Directive:
No
Packs per day: