Soap Note 2 Chronic Conditions (asthma)
Pick any Chronic Disease from Weeks 6-10 (asthma)
Must use the sample template for your soap note
, keep this template for when you start clinicals.
Follow the MRU Soap Note Rubric as a guide
Use APA format and must include a minimum of 2 Scholarly Citations.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
The use of the templates is ok with regards to Turn it in, but the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient.
(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).
.
Soap Note 2 Chronic Conditions (asthma)Pick any Chronic Dise.docx
1. Soap Note 2 Chronic Conditions (asthma)
Pick any Chronic Disease from Weeks 6-10 (asthma)
Must use the sample template for your soap note
, keep this template for when you start clinicals.
Follow the MRU Soap Note Rubric as a guide
Use APA format and must include a minimum of 2 Scholarly
Citations.
Soap notes will be uploaded to Moodle and put through TURN-
It-In (anti-Plagiarism program)
The use of the templates is ok with regards to Turn it in, but the
Patient History, CC, HPI, Assessment, and Plan should be of
your own work and individualized to your made-up patient.
(Student Name)
Miami Regional
University
2. 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:
4. 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:
5. 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
6. 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)
7. 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).
