SOAP NOTE TEMPLATE

SOAP NOTE TEMPLATE

SOAP NOTE TEMPLATE, This template should be used to complete SOAP notes throughout this course. Please choose a patient seen in the clinical setting to complete this note. You will include evidence-based practice guidelines in the management plan, and include rationales for differential diagnoses (cite source).  Please include a heart exam and lung exam on all clients regardless of the reason for seeking care.  So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam.  The pertinent positive and negative findings should be relevant to the chief complaint and health history data.  This template is a great example of information documented in a real chart in clinical practice  The term “Rule Out…” cannot be used as a diagnosis.Please describe appearance of area assessed and refrain from using the term “normal” when documenting this note.  Please note that requirements for SOAP notes may differ across NP courses.

1. Subjective Data

1. Chief Complain (CC):

1. History of Present Illness (HPI):

1. Last Menstrual Period (LMP- if applicable)

1. Allergies:

1. Past Medical History:

1. Family History:

1. Surgery History:

1. Social History (alcohol, drug or tobacco use):

1. Health Maintenance: ( include last PAP/MAM, immunizations, colonoscopy, PSA, last eye & physical exam, etc.)

1. Lifestyle Patterns (include spiritual beliefs, behaviors, and traditional practices)

1. Current medications:

1. Review of Systems (Remember to inquire about body systems relevant to the chief complaint & HPI)

1. Objective Data

 Please remember to include an assessment of all relevant systems based on the CC and HPI.  The following systems are required in all SOAP notes.  You will proceed to assess additional pertinent systems. 

 Vital Signs/ Height/Weight:

General Appearance:

HEART:

RESP:

1. Assessment

                         Differential Diagnosis (include rationales and cite source)

1.

2.

3.

Medical Diagnosis (include ICD 10 codes)

                         1.

                   B:  PLAN

1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided
2. Diagnostic testing
3. Problem oriented education
4. Health Promotion/Maintenance Needs
5. Cultural & Life span considerations
6. Referrals

 Follow-Up Plans(When will you schedule a follow-up appointment and what will you address in the subsequent visit —F/U in 2 weeks; Plan to check annual labs on RTC(return to clinic)

 Please include CPT Code (level of visit)

 References:  Please include at least 3 evidence-based sources in APA format.