2023 SOAP NOTE TEMPLATE SAMPLE Student Name Miami Regional University Date of Encounter Preceptor Clinical Site Clinical Instructor Dr David

Nursing 2023 SOAP NOTE : HERROMOIDS DISEASE

SOAP NOTE TEMPLATE SAMPLE Student Name Miami Regional University Date of Encounter Preceptor Clinical Site Clinical Instructor Dr David 2023 Assignment

  SOAP NOTE TEMPLATE SAMPLE

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, 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)

CONSTITUTIONAL

NEUROLOGIC

HEENT

RESPIRATORY

CARDIOVASCULAR

GASTROINTESTINAL

GENITOURINARY

MUSCULOSKELETAL

SKIN

Objective Data:

VITAL SIGNS: 

GENERAL APPREARANCE

NEUROLOGIC:

HEENT: 

CARDIOVASCULAR: 

RESPIRATORY: 

GASTROINTESTINAL: 

MUSKULOSKELETAL:

INTEGUMENTARY: 

ASSESSMENT:

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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