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3302 – My Nursing 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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