(Student Name)Miami Regional UniversityDate of Encounter

(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).
image1.png
Student’s Name
Miami Regional University
Date of Encounter: Mo/day/year
Preceptor/Clinical Site: MSN5600L Class
Clinical Instructor: Patricio Bidart MSN, APRN-IP, FNP-C
Soap Note # _____ Main Diagnosis: Dx: Herpes Zoster
PATIENT INFORMATION
Name: Ms. GP
Age: 78
Gender at Birth: Female

Gender Identity: Female
Source: Patient
Allergies: Peanut. Iodine
Current Medications:
bedtime
PMH:
I
-old
Immunizations: Flu vaccine in 2020, Covid -19 (Pfizer) in 2021
Preventive Care: Wellness exam on 03/2021
Surgical History: appendicectomy 20 years ago
Family History: daughter 48 years old / hyperlipidemia
Social History: Patient is widow, lives with her daughter.
Catholic religion. No alcohol. No

smoker. No history of drug used, sedentary lifestyle. Does not
work.
Sexual Orientation: Straight
Nutrition History: Regular diet, low in carbohydrates and fat.
Subjective Data:
Chief Complaint: I have been feeling itching and pain on my
right lower back” started 3 day
ago.
Symptom analysis/HPI: The patient is Ms. GP is 78-year-old
Hispanic woman, who is
complaining about itching, pain or tingling on her right lower
back. Patient stated that 3 days ago
she started to feel an increase in burning sensation on the area
taking all right lower back and
don’t relieve the pain with analgesic, she stated that wear any
clothes that touch the area is very
uncomfortable. Denies any episodes of fever but she feels
fatigue and chills and mild headache.
She stated that today in the morning she feel worse and noted
some redness in the area and
decided to come to the clinic to PCP evaluation.
Review of Systems (ROS)

CONSTITUTIONAL: fatigue, chills, denies weakness, no
thirsty, no loss of weight. No fever.
NEUROLOGIC: mild headache, no dizziness, no changes in
LOC, no loss of strength or
weakness/paresis/paralysis on extremities, no Hx of tremors or
seizures.
HEENT: denies any head injury, denies any pain
glasses for reading
through ear canal.
denies nasal bleeding. (No
epistaxis)
swallow
RESPIRATORY: patient denies shortness of breath, cough,
expectoration, or hemoptysis.
CARDIOVASCULAR: patient denies chest pain, tachycardia.
No orthopnea or paroxysmal
nocturnal dyspnea.

GASTROINTESTINAL: patient denies abdominal pain or
discomfort. Denies flatulence,
nausea, vomiting or diarrhea. (BM pattern) every other day, last
BM: today, no rectal bleeding
visible for her.
GENITOURINARY: patient denies polyuria, no dysuria, no
burning urination, no hematuria, no
lumbar pain, no urinary incontinence.
MUSCULOSKELETAL: denies falls or pain. Denies hearing a
clicking or snapping sound
SKIN: patient states itching, pain, or tingling sensation on her
right lower back.
HEMO/LYMPH/ENDOCRINE: glands swelling on groin, denies
bruising or abnormal
bleeding.
PSYCHIATRIST: patient denies anxiety, depression, denies
hallucinations or delusions, no
mood changes
Objective Data:
VITAL SIGNS:
Temperature: 98.4 °F, Pulse: 82x ‘, BP: 122/71 mm hg, RR 19,
PO2-97% on room air, Ht- 5’3”,

Wt 164 lb, BMI 30.2. Report pain 6/10.
GENERAL APPREARANCE: Adult, female. Alert and oriented
x 3.
NEUROLOGIC: Alert, oriented to person, place, and time.
Cranial nerves from I to XII intact.
Sensation intact to bilateral upper and lower extremities.
Bilateral UE/LE strength 5/5. Pupil
normal in size and equal. Deep tendon reflex presents.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-
tender. Maxillary sinuses no
tenderness.
extraocular eye movements
intact. No nystagmus noted. Wear glasses.
drainage, tympanic membrane
intact, pearly gray with sharp cone of light. No pain or edema
noted.

ue central, papillaes normal
distributed, no lesions
detected, present of upper and lower denture, fitting properly.
Lips with no lesions.
distention. No thyroid swelling or
masses, no thrills on auscultation.
CARDIOVASCULAR: S1S2, regular rate and rhythm, no
murmur or gallop noted. Capillary
refill < 2 sec. Peripheral pulses present and symmetric. No
edema on BLE.
RESPIRATORY: Lungs sounds clear. Chest wall symmetric
and no deformities, no intercostal
retractions, patient no noticed dyspnea, no orthopnea. No
egophony, no pectoriloquy, no fremitus
or sign of condensation tissue on palpation. Resonance equal in
both hemithorax. Lungs: breath
sounds present and clear on auscultation, no rales, no wheezing,
no rhonchi.
GASTROINTESTINAL: Abdomen soft and non-tender.
Continent to BB. Bowel sounds

present in all four quadrants; no bruits present over aortic or
renal arteries. Last BM today.
GENITOURINARY: Costovertebral angles non-tenders, kidneys
no palpable. External
genitalia present, no enlargement, no tumors palpable. Groins
area noted with redness.
MUSKULOSKELETAL: No pain to palpation. Active and
passive ROM within normal limits,
no stiffness.
INTEGUMENTARY: painful redness rash, with crops of
vesicles on an erythematous base
with a few satellite lesions in linear distribution, do not cross
midline, some of the blisters are
filled with purulent fluids and other are crusted. Area is swollen
and redness.
ASSESSMENT:
Patient Ms. GP is 78-year-old Hispanic woman with Hx of DM
Type II and Hyperlipidemia,
came into our clinic today complaining about itching, pain and
tingling on her right lower back
starting 3 days ago. During the physical exam was noted painful
redness rash, with crops of
vesicles on an erythematous base with a few satellite lesions in

linear distribution, which do not
cross midline. Diagnosis is based on the clinical evaluation
through history and physical
examination. According to patient presentation, signs and
symptoms patient is diagnosed with
herpes zoster. Patients falls into the high risk group based on
Buttaro (2017). Herpes zoster is
viral infection that occurs with reactivation of the varicella -
zoster virus and the patient referred
has history of Chickenpox when she was 20 years old.
Main Diagnosis
Herpes Zoster (ICD10 B02.9): Herpes zoster is infection that
results when varicella-zoster virus
reactivates from its latent state in a posterior dorsal root
ganglion. Symptoms usually begin with
pain along the affected dermatome, followed within 2 to 3 days
by a vesicular eruption that is
usually diagnostic. (Domino, Baldor, Golding,
&Stephens,2017).
Other diagnosis:
Diabetes mellitus type II. (ICD-10 E11.9)

Hyperlipidemia. (ICD-10 E78.5)
Differential diagnosis
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
Pharmacological treatment:
is less likely to be effective if
given > 72 hours after skin lesions appear,
-reliever NSAIDs
gabapentin, pregabalin)
Continue with current medication for chronic condition:

bedtime
et PO once a day
Non-Pharmacologic treatment:
calamine to refresh the area.
Education
caution – Type Contact
kids and
Immunocompromised patient.
Follow-ups/Referrals
Follow up appointment 2 weeks / No referral needed at this time
Call if the symptoms are worse or you noticed any adverse
reaction.

References
Buttaro, T. M., Trybulski, J. A., Polgar-Bailey, P., & Sandberg-
Cook, J. (2017). Primary care: a
collaborative practice. St. Louis, MO: Elsevier.
Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The
5-Minute Clinical Consult 2017
(25th ed.). Print (The 5-Minute Consult Series).
McCance, K. L., & Huether, S. E. (2019). Pathophysiology: the
biologic basis for disease in
adults and children. St. Louis, MO: Elsevier.
Grading Rubric
Student______________________________________
This sheet is to help you understand what we are looking for,
and what our margin remarks might be about on your write ups
of patients. Since at all of the white-ups that you hand in are
uniform, this represents what MUST be included in every write-
up.
1)
Identifying Data (___5pts): The opening list of the note.
It contains age, sex, race, marital status, etc. The patient
complaint should be given in quotes. If the patient has more
than one complaint, each complaint should be listed separately
(1, 2, etc.) and each addressed in the subjective and under the

appropriate number.
2)
Subjective Data (___30pts.): This is the historical part
of the note. It contains the following:
a) Symptom analysis/HPI(Location, quality , quantity or
severity, timing, setting, factors that make it better or worse,
and associate manifestations.(10pts).
b) Review of systems of associated systems, reporting all
pertinent positives and negatives (10pts).
c) Any PMH, family hx, social hx, allergies, medications related
to the complaint/problem (10pts). If more than one chief
complaint, each should be written u in this manner.
3)
Objective Data(__25pt.): Vital signs need to be present.
Height and Weight should be included where appropriate.
a) Appropriate systems are examined, listed in the note and
consistent with those identified in 2b.(10pts).
b) Pertinent positives and negatives must be documented for
each relevant system.
c) Any abnormalities must be fully described. Measure and
record sizes of things (likes moles, scars). Avoid using “ok”,
“clear”, “within normal limits”, positive/ negative, and
normal/abnormal to describe things. (5pts).
4)
Assessment (___10pts.): Encounter paragraph and
diagnoses should be clearly listed and worded appropriately
including ICD10 codes.

5)
Plan (___15pts.): Be sure to include any teaching,
health maintenance and counseling along with the
pharmacological and non-pharmacological measures. If you
have more than one diagnosis, it is helpful to have this section
divided into separate numbered sections.
6)
Subjective/ Objective, Assessment and Management and
Consistent (___10pts.): Does the note support the appropriate
differential diagnosis process? Is there evidence that you know
what systems and what symptoms go with which complaints?
The assessment/diagnoses should be consistent with the
subjective section and then the assessment and plan. The
management should be consistent with the assessment/
diagnoses identified.
7)
Clarity of the Write-up(___5pts.): Is it literate,
organized and complete?
Comments:
Total Score: ____________
Instructor: __________________________________
Guidelines for

Focused SOAP Notes
·
Label each section of the SOAP note (each body part
and system).
·
Do
not use unnecessary words or complete sentences.
·
Use Standard Abbreviations
S: SUBJECTIVE DATA (information the patient/caregiver tells
you).
Chief Complaint (CC): a statement describing the patient’s
symptoms, problems, condition, diagnosis, physician-
recommended return(s) for this patient visit. The patient’s own
words should be in quotes.
History of present illness (HPI): a chronological description of
the development of the patient's chief complaint from the first
symptom or from the previous encounter to the present. Include
the eight variables (Onset, Location, Duration, Characteristics,
Aggravating Factors, Relieving Factors, Treatment, Severity-
OLDCARTS), or an update on health status since the last
patient encounter.
Past Medical History (PMH): Update current medications,
allergies, prior illnesses and injuries, operations and
hospitalizations allergies, age-appropriate immunization status.
Family History (FH): Update significant medical information
about the patient's family (parents, siblings, and children).
Include specific diseases related to problems identified
in CC, HPI or ROS.
Social History(SH): An age-appropriate review of significant
activities that may include information such as marital status,

living arrangements, occupation, history of use of drugs,
alcohol or tobacco, extent of education and sexual history.
Review of Systems (ROS). There are
14 systems for review. List positive findings and
pertinent negatives in systems directly related to the systems
identified in the CC and symptoms which have occurred since
last visit; (1) constitutional symptoms (e.g., fever, weight loss),
(2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular,
(5) respiratory, (6) gastrointestinal, (7) genitourinary, (8)
musculoskeletal, (9-}.integument (skin and/or breast), (10)
neurological, (11) psychiatric, (12) endocrine, (13)
hematological/lymphatic, {14) allergic/immunologic. The ROS
should mirror the PE findings section.
0: OBJECTIVE DATA (information you observe, assessment
findings, lab results).
Sufficient physical exam should be performed to evaluate areas
suggested by the history and patient's progress since last visit.
Document specific abnormal and relevant negative findings.
Abnormal or unexpected findings should be described.
You should include only the information which was
provided in the case study, do not include additional data.
Record observations for the following systems if applicable to
this patient encounter (there are 12 possible systems for
examination): Constitutional (e.g. vita! signs, general
appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory,
GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric,
Hematological/lymphatic/immunologic/lab testing. The
focused PE should only include systems for which you have
been given data.
NOTE:
Cardiovascular and Respiratory systems should be
assessed on every patient regardless of the chief complaint.
Testing Results: Results of any diagnostic or lab testing ordered

during that patient visit.
A: ASSESSMENT: (this is your diagnosis (es) with the
appropriate ICD 10 code)
List and number the possible diagnoses (problems) you have
identified. These diagnoses are the conclusions you have drawn
from the subjective and objective data.
Remember:Your subjective and objective data should support
your diagnoses and your therapeutic plan.
Do not write that a diagnosis is to be "ruled out" rather state the
working definitions of each differential or primary diagnosis
(es).
For each diagnoses provide a cited rationale for choosing this
diagnosis. This rationale includes a one sentence cited
definition of the diagnosis (es) the pathophysiology, the
common signs and symptoms, the patients presenting signs and
symptoms and the focused PE findings and tests results that
support the dx. Include the interpretation of all lab data given in
the case study and explain how those results support your
chosen diagnosis.
P: PLAN (this is your treatment plan specific to this patient).
Each step of your plan must include an EBP citation.
1. Medications write out the prescription including dispensing
information and provide EBP to support ordering each
medication. Be sure to include both prescription and OTC
medications.
2. Additional diagnostic tests include EBP citations to support
ordering additional tests
3. Education this is part of the chart and should be brief, this is
not a patient education sheet and needs to have a reference.

4. Referrals include citations to support a referral
5. Follow up. Patient follow-up should be specified with time or
circumstances of return. You must provide a reference for your
decision on when to follow up.

(Student Name)Miami Regional UniversityDate of Encounter

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