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SOAP Note Chronic Condition

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 guideUse 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 UniversityDate of Encounter:Preceptor/Clinical Site:Clinical Instructor: Patricio Bidart MSN, APRN, FNP-CSoap Note # ____   Main Diagnosis ______________PATIENT INFORMATIONName: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 earpain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and thatetc.)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/ReferralsReferences (in APA Style)ExamplesCodina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).ISBN 978-0-8261-3424-0Domino, 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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