SOAP note format

Clinical Case Presentations

Students must post one interesting case that he/she has seen in the clinical setting via Discussion Board in the online part of this course. The case should be an unusual diagnosis, or a complex case that required in-depth evaluation on the student’s part. The case should be posted in the SOAP format, with references for the patient diagnosis, differential diagnoses (there should be at least 3), and the treatment plan. Notes will be graded as “pass/fail”. In order to receive grade points for SOAP notes, the notes must be approved by the deadlines specified on the course assignments page. The student will lose the opportunity for points on any SOAP notes not approved by the specified deadlines. The posting does not have to be written in APA format, but should be written with correct spelling and grammar. References should be in APA format. The selected references should reflect current evidence – dated within the past 5 years. See rubric in the syllabus section  

Follow the Soap Note Rubric as a guide:

Use APA format and must include minimum of 2 Scholarly Citations.

Soap Note Rubric:

  

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: 

Soap Note # 1     Main Diagnosis: Acute Myocardial Infarction

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 APPEARANCE: 

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).

I attached one example:

Please no plagiarism!!!

 I am going to ask the class to share various articles on research (topics include: quantitative research, qualitative research, literature review, experimental research design). Please upload it to the discussion board (There are no formal discussions noted for this week – Just upload an article on the topics mention to share with your class). Just let us know what the article is about. This will help your colleagues gain an understanding of our process as we go into Phase One of our research course.  

This week, you will write your evidence-based change project status report, which gives you an opportunity to share your progress. The report should provide evidence of your critical thinking and ability to apply research and project management principles in the clinical setting.
  The requirements of this assignment include: 1.Identify obstacles and steps taken to manage and stabilize successful implementation of your change project thus far. 2.Discuss the project implementation to date, the resources used, and continued support needed. 3.Identify expected project outcomes and any timeline adjustments needed. 4.Discuss a summary of the project, the main points, and the findings, the significance of the project to the nursing profession, and any recommendations for future research.  You will submit a written paper using the format of the APA (6th ed.), including cover page, proper headings and references. The report should be at least 4 pages in length, not including the cover page and references.