Pharmacological treatment:

Soap Note 1 Acute Conditions

Pick any Acute Disease from Weeks 1-5   (  ACUTE BRONCHITIS )

Must use the sample template for your soap note, keep this template for when you start clinicals.

Late Assignment Policy

Assignments turned in late will have 1 point taken off for everyday assignment is late, after 7 days assignment will get a grade of 0. No exceptions 

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)

Turn it in Score must be less than 25% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 25%. Copy-paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.

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. 

  • Soap Note 1 Acute ConditionsAssignment
    Soap Note 1 Acute Conditions (10 points)

    Follow the MRU Soap Note Rubric as a guide:
    Use APA format and must include mia minimum of 2 Scholarly Citations.

    Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

    Turn it in’ s Score must be less than 25% or will not be accepted for credit; it must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 25%. Copy-paste from websites or textbooks will not be accepted or tolerated and will receive a grade of 0 (zero) with no resubmissions allowed.

    Please see College Handbook regarding Academic Misconduct Statement.
    Must use the sample templates for your soap note. Keep this template for when you start clinicals. 

    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. 

(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).