Soap Note 1 Acute Conditions
Follow the MRU Soap Note Rubric as a guide:
Use APA format and must include minimum of 2 Scholarly Citations.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.
Must use the sample templates for your soap note, keep this template for when you start clinicals.
The use of tempates is ok with regards of Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.
Miami Regional University
Date of Encounter:
Clinical Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C
Soap Note # ____ Main Diagnosis ______________
Gender at Birth:
The patient is …
Review of Systems (ROS)
(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)
Labs and Diagnostic Test to be ordered (if applicable)
Education (provide the most relevant ones tailored to your patient)
References (in APA Style)
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
(25th ed.). Print (The 5-Minute Consult Series).