EPISODIC SOAP NOTE TEMPLATE

EPISODIC SOAP NOTE TEMPLATE

Please role play with a volunteer family member or friend to complete this Assignment. You will focus on a respiratory disorder and gather data to complete an episodic SOAP note. You will include evidence-based practice guidelines in the management plan, and include rationales for differential diagnoses (cite source). Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart, and Lungs for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice. The term “Rule Out…” cannot be used as a diagnosis. Please describe appearance of area assessed and refrain from using the term “normal” when documenting this note. Please note that requirements for SOAP notes may differ across NP courses.

I. Subjective Data

A. Chief Complain (CC):

B. History of Present Illness (HPI):

C. Last Menstrual Period (LMP- if applicable)

D. Allergies:

E. Past Medical History:

F. Family History:

G. Surgery History:

H. Social History (alcohol, drug or tobacco use):

I. Current medications:

J. Review of Systems (Remember to inquire about body systems relevant to the chief complaint and HPI)

II. Objective Data

Please remember to include an assessment of all relevant systems based on the CC and HPI. The following systems are required in all SOAP notes. You will proceed to assess additional pertinent systems.

Vital Signs/ Height/Weight:

General Appearance:

HEART:

RESP:

A. Assessment

Differential Diagnosis (includes rationales and cites sources)

1.
2.
3.

Medical Diagnosis

1.

B: PLAN

1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided
2. Diagnostic testing
3. Problem oriented education
4. Health Promotion/Maintenance Needs
5. Cultural & Life span considerations
6. Referrals

Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit? Follow-up in 2 weeks; and plan to check annual labs on return to clinic (RTC))

References: Please include at least 3 evidence-based sources in APA format.

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