Posted: May 1st, 2022

Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C

(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).

——

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

Soap Note #

INFORMATION ABOUT THE PATIENT
Name: sAge:
Birth Gender:
Gender Identification:
Allergies:
Medications in Use:
• PMH: Vaccinations:
Preventive Medicine:
Surgical Background:
Social History: Family History: Sexual Orientation:
History of Nutrition:

Subjective Information:
The patient is…, according to the symptom analysis/HPI.

System Evaluation (ROS) (Because this section is what the patient says, it should begin with Pt denies or Pt states…..)
CONSTITUTIONAL:
NEUROLOGIC:
HEENT: RESPIRATORY: CARDIOVASCULAR: GASTROINTESTINAL: GENITOURINARY: MUSCULOSKELETAL: SKIN: SKIN: SKIN: SKIN: SKIN: SKIN: SKIN: SKIN: SKIN: SKIN: SKIN: SKIN: SKIN: SKIN:

VITAL SIGNS: OBJECTIVE DATA:

OVERALL APPEARANCE:
NEUROLOGIC:
CARDIOVASCULAR: HEENT
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