Template and rubric are included. SOAP NOTE TEMPLATE Review the Rubric for more Guidance Demographics

 Template and rubric are included.

SOAP NOTE TEMPLATE

Review the Rubric for more Guidance

Demographics

Chief Complaint (Reason for seeking health care)

History of Present Illness (HPI)

Allergies

Review of Systems (ROS)

General:

HEENT:

Neck:

Lungs:

Cardio

Breast:

GI:

M/F genital:

GU:

Neuro

Musculo:

Activity:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

Vital Signs

Labs

Medications

Past Medical History

Past Surgical History

Family History

Social History

Health Maintenance/ Screenings

Physical Examination

General:

HEENT:

Neck:

Lungs:

Cardio

Breast:

GI:

M/F genital:

GU:

Neuro

Musculo:

Activity:

Psychosocial:

Derm:

Diagnosis

Differential Diagnosis

ICD 10 Coding

Pharmacologic treatment plan

Diagnostic/Lab Testing

Education

Anticipatory Guidance

Follow up plan

Prescription

See Below (scroll down)

References

Grammar

EA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age ___________

Date: _______________

RX ______________________________________

SIG:

Dispense: ___________ Refill: _________________

No Substitution

Signature:____________________________________________________________

Signature (with appropriate credentials):_____________________________________

References (must use current evidence-based guidelines used to guide the care [Mandatory])

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

NURS-6051C-47 (05/26/2025-08/10/2025)-PT27 please respond to the posts attached.  Rebecca Brown Jun 10 7:09pm Manage

NURS-6051C-47 (05/26/2025-08/10/2025)-PT27 please respond to the posts attached.  Rebecca Brown Jun 10 7:09pm Manage Discussion by Rebecca Brown Reply from Rebecca Brown Implementation Healthcare electronic documentation technology has been recently introduced for my current employer in the maximum-security prison for the Department of Corrections. The newly designed electronic record platform

Week 6 Discussion Part I Table 1 Differential Diagnosis Pediatric Limp

Week 6 Discussion Part I Table 1 Differential Diagnosis Pediatric Limp Complete the table. CC limp Condition Age Pain (+ or -) Historical Findings Clinical Findings Causative Factors Management Developmental Dysplasia of Hip Leg-length Inequality Juvenile Arthritis Slipped capital femoral epiphysis (SCFE) Legg-Calve-Perthes disease Transient synovitis Trauma Neoplasm Septic arthritis

MENTAL STATUS EXAM GUIDE Previous Mental Health Treatments (e g: psychopharmacology, inpatient stabilization, Occupational

MENTAL STATUS EXAM GUIDE Previous Mental Health Treatments (e g: psychopharmacology, inpatient stabilization, Occupational Therapy, Vocational Therapy, Marriage/Family Therapy, Group Therapy, Detox, ECT &/or social services): What is the initial impression of the admitting examiner found in the initial evaluation, triage, or social worker note: Compare your impression of the

Comprehensive Psychiatric Evaluation Template With Psychotherapy Note Encounter date:

Comprehensive Psychiatric Evaluation Template With Psychotherapy Note Encounter date: ________________________ Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____ Reason for Seeking Health Care: ______________________________________________ HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ SI/HI: _______________________________________________________________________________ Sleep:  _________________________________________         Appetite:  ________________________ Allergies (Drug/Food/Latex/Environmental/Herbal): ___________________________________ Current perception of Health: Excellent Good Fair Poor

1

1 3 Awakening the DNP Spirit of the Scientific Underpinnings Your Name (without credentials) Miami Regional University DNP7100: Evaluation of Evidence for Practice Professor Name Month, Year Title (Introduction – not labeled ‘Introduction’) Introduce your topic of interest for practice change and its general area of either (a) clinical outcomes,

Describe causes of Upper respiratory infections and drug therapy  Discuss triggers of asthma and treatment options Discuss corticosteroids  Describe

Describe causes of Upper respiratory infections and drug therapy  Discuss triggers of asthma and treatment options Discuss corticosteroids  Describe chronic bronchitis and treatment options Describe diagnostic criteria for nausea and vomiting and treatment recommendations Discuss symptoms of GERD, complications, and drug management Compare and contrast Crohn’s disease and Ulcerative colitis