the MRU Soap Note Rubric as a guide Use APA format and must include minimum of 2 Scholarly Citations.

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Student Name)

Miami Regional University

Date of Encounter:

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Preceptor/Clinical Site:

Clinical Instructor: Patricio Bidart MSN, APRN, 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) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )

CONSTITUTIONAL:

NEUROLOGIC:

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