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.
Miami Regional University
Date of Encounter:
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C
Soap Note # ____ Main Diagnosis ______________
Gender at Birth:
The patient is …
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
(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.)
(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)
Labs and Diagnostic Test to be ordered (if applicable)
• – • –
Education (provide the most relevant ones tailored to your patient)
References (in APA Style)
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
(25th ed.). Print (The 5-Minute Consult Series)