(Student Name)<\/p>\n
Miami Regional University<\/p>\n
Date of Encounter:<\/p>\n
Preceptor\/Clinical Site:<\/p>\n
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C<\/p>\n
Soap Note # ____ Main Diagnosis ______________<\/p>\n
PATIENT INFORMATION<\/p>\n
Name:<\/p>\n
Age:<\/p>\n
Gender at Birth:<\/p>\n
Gender Identity:<\/p>\n
Source:<\/p>\n
Allergies:<\/p>\n
Current Medications:<\/p>\n
\u00b7<\/p>\n
PMH:<\/p>\n
Immunizations:<\/p>\n
Preventive Care:<\/p>\n
Surgical History:<\/p>\n
Family History:<\/p>\n
Social History:<\/p>\n
Sexual Orientation:<\/p>\n
Nutrition History:<\/p>\n
Subjective Data:<\/p>\n
Chief Complaint:<\/p>\n
Symptom analysis\/HPI:<\/p>\n
The patient is \u2026<\/p>\n
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states\u2026.. )<\/p>\n
CONSTITUTIONAL:<\/p>\n
NEUROLOGIC:<\/p>\n
HEENT:<\/p>\n
RESPIRATORY:<\/p>\n
CARDIOVASCULAR:<\/p>\n
GASTROINTESTINAL:<\/p>\n
GENITOURINARY:<\/p>\n
MUSCULOSKELETAL:<\/p>\n
SKIN:<\/p>\n
Objective Data:<\/p>\n
VITAL SIGNS:<\/p>\n
GENERAL APPREARANCE:<\/p>\n
NEUROLOGIC:<\/p>\n
HEENT:<\/p>\n
CARDIOVASCULAR:<\/p>\n
RESPIRATORY:<\/p>\n
GASTROINTESTINAL:<\/p>\n
MUSKULOSKELETAL:<\/p>\n
INTEGUMENTARY:<\/p>\n
ASSESSMENT:<\/p>\n
(In a paragraph please state \u201cyour encounter with your patient and your findings ( including subjective and objective data)<\/p>\n
Example : \u201cPt 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\u2026 on examination I noted this and that etc.)<\/p>\n
Main Diagnosis<\/p>\n
(Get custom essay samples and course-specific study resources via\u00a0course hero homework for you service – Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Get custom essay samples and course-specific study resources via\u00a0course hero homework for you service – Include the in-text reference\/s as per Ace homework tutors – APA style 6th or 7th Edition.<\/p>\n
Differential diagnosis (minimum 3)<\/p>\n
–<\/p>\n
–<\/p>\n
–<\/p>\n
PLAN:<\/p>\n
Labs and Diagnostic Test to be ordered (if applicable)<\/p>\n
\u00b7 –<\/p>\n
\u00b7 –<\/p>\n
Pharmacological treatment:<\/p>\n
–<\/p>\n
Non-Pharmacologic treatment:<\/p>\n
Education (provide the most relevant ones tailored to your patient)<\/p>\n
Follow-ups\/Referrals<\/p>\n
References (in Ace homework tutors – APA Style)<\/p>\n
Examples<\/p>\n
Codina Leik, M. T. (2014: 2024 – Essay Writing Service | Write My Essay For Me Without Delay). Family Nurse Practitioner Certification Intensive Review (2nd ed.).<\/p>\n
ISBN 978-0-8261-3424-0<\/p>\n
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010 – Essay Writing Service: Write My Essay by Top-Notch Writer). The 5-Minute Clinical Consult 2010 – Essay Writing Service: Write My Essay by Top-Notch Writer<\/p>\n
(25th ed.). Print (The 5-Minute Consult Series).<\/p>\n","protected":false},"excerpt":{"rendered":"
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