Soap note chronic condition | Nursing homework help

Soap Note 2 Chronic Conditions (asthma)

Pick any Chronic Disease from Weeks 6-10 (asthma)

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

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)

The use of the 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).

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