Description
Soap Note 1 – Any Acute or Chronic Condition
Pick any Chronic Disease from (See word document)
Must use the sample template for your soap note
,
Use APA format and must include a minimum of 2 Scholarly Citations.
Must be your own work and in your own words.
The use of 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.
Conditions SOAP Note 1
1. Immunologic Diseases and Disorders
2. Guillain-Barr? Syndrome
3. HIV/AIDS
4. Hodgkin Lymphoma
5. Leukemia
6. Lupus
7. Multiple Myeloma
8. Multiple Sclerosis
9. Scleroderma
10. Sj?gren Syndrome
11. Acne
12. Burns
13. Dermatitis
14. Impetigo
15. Lyme Disease
16. Melanoma
17. Methicillin-Resistant Staphylococcus Aureus (MRSA)
18. Pediculosis (Lice)
19. Psoriasis
20. Tinea (Capitis, Corporis, Cruris, Pedis)
21. Scabies
22. Stevens-Johnson S.
23. Acute Coronary Syndrome
24. Anemia
25. Aneurysm of the Abdominal Aorta (Triple A)
26. Atrial Fibrillation & Flutter
27. Carotid Stenosis
28. Deep Vein Thrombosis
29. Endocarditis
30. Heart Failure
31. Hemophilia
32. Heparin-Induced Thrombocytopenia
33. Hypercholesterolemia
34. Hypertension
35. Mitral Valve Prolapse, Regurgitation, Stenosis
36. Peripheral Arterial Disease
37. Raynaud Phenomenon
38. Rhabdomyolysis
39. Rocky Mountain Spotted Fever
40. Asthma
41. Atelectasis
42. Basal/Squamous Cell Carcinoma
43. Bronchitis
44. Chronic Obstructive Pulmonary Disease and Emphysema
45. Cystic Fibrosis
46. Influenza
47. Legionnaires’ Disease
48. Sleep Apnea, Obstructive
49. Pleural Effusion
50. Pneumonia
51. Pulmonary Emboli
52. Sarcoidosis
53. Tuberculosis (TB)
(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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