Insomnia MRUMSN5700CSOAPNOTETemplate2023.docx (Student Name)

Insomnia

MRUMSN5700CSOAPNOTETemplate2023.docx

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site: Ciro A. Ramirez/ South FL MD Group

Clinical Instructor: Leonardo Trobajo Lobayna

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) (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 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.)

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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SoapNoteGradingRubric.pdf

Soap Note Grading Rubric

This sheet is to help you understand what is required, and what the margin remarks might

be about on your comments of patients. Since most of the comments that you hand in are

uniform, this represents what MUST be included in every write-up.

1) Identifying Data (__5- 5pts): The opening list of the note. It contains age, sex, race, marital

status, etc. The patient complaint should be given in quotes. If the patient has more than

one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in

the subjective and under the appropriate number.

2) Subjective Data (_30__30pts.): This is the historical part of the note. It contains the

following:

a) Symptom analysis/HPI (Location, quality, quantity or severity, timing, setting, factors that

make it better or worse, and associate manifestations. (10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives

(10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem

(10pts). If more than one chief complaint, each should be written in this manner.

3) Objective Data(_25_25pt.): Vital signs need to be present. Height and Weight should be

included where appropriate.

a) Appropriate systems are examined, listed in the note and consistent with those identified

in 2b.(10pts).

b) Pertinent positives and negatives must be documented for each relevant system.

c) Any abnormalities must be fully described. Measure and record sizes of things (likes

moles, scars). Avoid using ??ok?, ??clear?, ??within normal limits?, positive/ negative, and

normal/abnormal to describe things. (5pts).

4) Assessment (_10__10pts.): All diagnoses should be clearly listed and worded

appropriately with ICD 10 codes. Rationale and Explanation must be evidence based and

have 1-2 in text references to back up you??re reasoning for making your main diagnosis

selection. 3 differential diagnoses must be noted, rationale not required but encouraged.

5) Plan (_15__15pts.): Be sure to include any teaching, health maintenance and counseling

along with the pharmacological and non-pharmacological measures. If you have more than

one diagnosis, it is helpful to have this section divided into separate numbered sections.

Should not be generic information and should be tailored to your patient and their needs /

specific diagnosis.

6) Subjective/ Objective, Assessment and Management and Consistent (__10_10pts.): Does

the note support the appropriate differential diagnosis process? Is there evidence that you

know what systems and what symptoms go with which complaints? The

assessment/diagnoses should be consistent with the subjective section and then the

assessment and plan. The management should be consistent with the assessment/

diagnoses identified.

Clarity of the Write-up(__5_5pts.): Is it literate, organized, and complete?

TOTAL: __100______

Leonardo Trobajo, MSN, APRNP, AGPCNP-BC, AGACNP-BC

CLINICAL INSTRUCTOR:

Professor at MSN/FNP Program