Endocarditis soap note
You must use this template for Soap note 1 and 2. Use the information provided in the PDF as an “EXAMPLE”. You must use the word temple file and tailor it to your patient and their diagnosis. Using this template will make it very easy to learn the things needed in the note and help you not forget to put something or lose points due to incorrect format or missing information.
The Chief Complaint, Patient info, HPI, Plan section, and references must all be of your own work and no copy-paste.
The Main Areas of Focus that will be checked for plagiarism is Chief Complain, History of Present Illness (HPI), Assessment with Rationale and Explanation, and the Plan. All of this should be in your own words and not copy-pasted from a past note or website or book. There should be minimum likeness noted by turn it in software in these areas.
The Objective and Subjective information can be from a template (Standard Documentation) and will only be looked at for content and not for plagiarism. So if you are past 50% and the above main areas of focus sections are clear and minimum then you are ok. You can resubmit as many times but after 3 it takes up to 24 hours to get turn it in a score.
This is a made-up patient, so review your diagnosis and have the patient have the standard presentation, objective and subjective symptoms that would typically present and adjust them on
(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)
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–
–
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).