Assignment Prompt & Instructions
– ## TemplateFNPSOAPNote-1.docx
**## TemplateFNPSOAPNote-1.docx**
**FNP SOAP Note Template**
Use this template for Comprehensive Notes (H&Ps) and Problem-Focused Notes (Episodic/progress notes). For the Problem-Focused Notes,
_only_ include pertinent problem-focused information related to the chief concern (CC).
**Demographic Data**
· Patient age and gender identity
· MUST BE HIPAA compliant
**Subjective**
**Chief Complaint (CC)**
· Place the complaint in Quotes
· Brief description -only a few words and in the patient’s words … “My chest hurts,” “I cannot breath,” or “I passed out,” etc.
**History of Present Illness (HPI)**– the
**reason for the appointment today**
· Use the OLD CARTS acronym to document the eight elements of a chief concern (CC): Onset, Location/radiation, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity)
· Briefly describe the general state of health prior to the problem.
· Are Activities of Daily Living (ADL) impacted by the current problem?
**Past Medical History**:
· List current and past medical diagnoses
**Past Surgical History**:
· List all past surgeries
**FAMILY HISTORY:**
· Include medical/psychiatric problems to include 3 generations (parents, grandparents, siblings, or
direct relatives.
**Current Medications:**
· Include current prescription(s), over-the-counter medications, herbal/alternative medications as well as vitamin/supplement use.
**ALLERGIES**: Include medications, foods, and chemicals such as latex.
**Immunizations History:** list current immunization status and address deficiency
**Preventative health History: (** See Table below – Appendix A)
**SOCIAL HISTORY:**
·
**Include** nutrition, exercise, substance use (details of use: caffeine, EtOH, illicit drug use), sexual history/preference, financial problems, legal issues, kids, and history of abuse, including sexual, emotional, or physical.
·
**Employment/Education:** occupation (type), exposure to harmful agents, highest school achievement
**REVIEW OF SYSTEMS:**
· A ROS is a question-seeking inventory by body systems to identify signs and/or symptoms that the patient may be experiencing or has experienced that may or may not correlate with the CC.
*If a + finding is found not related to the cc this may represent an additional problem that will need to be detailed in the HPI.
· Must include any physical complaint(s) by the body system that is relevant to the treatment and management of the current concern(s).
**List only the pertinent body systems specific to the CC.**
·
Remember to include pertinent positive and negative findings when detailing the ROS related to a chief concern (cc).
·
Do not repeat the information provided in HPI
· Use the format below when detailing the ROS
**ROS:**
General:
Eyes:
Ears, nose, mouth & throat:
Cardiovascular:
Respiratory:
Gastrointestinal:
Skin & Breasts:
Musculoskeletal:
Allergic:
Immunologic:
Endocrine:
Hematopoietic/Lymphatic:
Genitourinary:
Neurological:
Psychiatric/Mental Status:
**Objective**
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure. Heart rate (regular or irregular). Respirations. SaO2 (on room air or O2). Temperature. Weight. Height.
*Document the presence of any internal/external devices (IV, Central lines, NGTs, G-tubes, Ostomies, urinary catheters) and dates of placement.
General:
Eyes:
Ears, nose, mouth & throat:
Cardiovascular:
Respiratory:
Gastrointestinal:
Skin & Breasts:
Musculoskeletal:
Allergic:
Immunologic:
Endocrine:
Hematopoietic/Lymphatic:
Genitourinary:
Neurological:
Psychiatric/Mental Status:
**Pertinent Diagnostic Test Results:**
**Assessment (Diagnosis)**
Differential Diagnosis (DDx)
· Include two (2) differential diagnoses you considered but did not select as the final diagnosis. Why were these 2 diagnoses not selected? Support with pertinent positive and negative findings for each differential with an evidence-based guideline(s) (required).
Working or Final Diagnosis:
· Final or working diagnosis (1) (including ICD-10 code)
· Provide a rational explanation supported by evidenced-based guidelines (required). List the pertinent positive and negative symptoms/signs that support your final diagnosis.
**Plan**
Treatment (Tx) Plan: pharmacologic and/or nonpharmacologic
· Pharmacologic -include full prescribing information for each medication(s) ordered
· Refill Provided: Include full prescribing information for each medication(s) refilled and the correlating diagnosis related to the refill.
Patient Education:
· Include specific education related to each medication prescribed.
· Was risk versus benefit of current treatment plan addressed for medication(s) and interventions? Was the patient included in the medical decision making and in agreement with the final plan
· NPs should not be prescribing non-FDA approved medications or medications related to off-label use. If a physician prescribed a non-FDA-approved medication for working diagnosis or recommended off-label use was education provided and was the risk to benefit of the medication(s) addressed in the patient’s education?
Prognosis Good, Fair, or Poor?
· Indicate the patient’s prognosis: Good, Fair, Poor
· Provide support for your selected prognosis
Referral/Follow-up
· Did you recommend follow-up with PCP, or other healthcare professionals?
· When is the subsequent follow-up?
Disposition:
· Indicate the disposition of the patient.
· Was the patient sent home, Emergency room via EMS, etc.
· Include rationale for the follow-up recommendation or referral
Reference(s)
· Include APA formatted references for written assignments.
· Minimum 2 references are required from evidence-based resources.
· Oral assignments should include verbally articulated evidence-based guideline(s) used to prepare the oral presentation.
APPENDIX A
**PREVENTATIVE CARE SCHEDULE (Example – not all-inclusive)**
| | | | |
| — | — | — | — |
| Preventive Care | Date | Result | Referrals Made |
| Pap | | | |
| Mammogram | | | |
| A1C | | | |
| Eye Exam | | | |
| Monofilament Test | | | |
| Urine<br>Microalbumin | | | |
| Diet/Lifestyle Modifications | | | |
| Digital Rectal Exam (DRE) | | | |
| PSA | | | |
| Colonoscopy or FOBT | | | |
| Dexa Scan | | | |
| CXR | | | |
| BNP | | | |
| ECG | | | |
| Echo | | | |
| Stress <br>Test | | | |
| | | | |
| Vaccines | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
**## TemplateFNPSOAPNote-1.docx**
**FNP SOAP Note Template**
Use this template for Comprehensive Notes (H&Ps) and Problem-Focused Notes (Episodic/progress notes). For the Problem-Focused Notes,
_only_ include pertinent problem-focused information related to the chief concern (CC).
**Demographic Data**
· Patient age and gender identity
· MUST BE HIPAA compliant
**Subjective**
**Chief Complaint (CC)**
· Place the complaint in Quotes
· Brief description -only a few words and in the patient’s words … “My chest hurts,” “I cannot breath,” or “I passed out,” etc.
**History of Present Illness (HPI)**– the
**reason for the appointment today**
· Use the OLD CARTS acronym to document the eight elements of a chief concern (CC): Onset, Location/radiation, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity)
· Briefly describe the general state of health prior to the problem.
· Are Activities of Daily Living (ADL) impacted by the current problem?
**Past Medical History**:
· List current and past medical diagnoses
**Past Surgical History**:
· List all past surgeries
**FAMILY HISTORY:**
· Include medical/psychiatric problems to include 3 generations (parents, grandparents, siblings, or
direct relatives.
**Current Medications:**
· Include current prescription(s), over-the-counter medications, herbal/alternative medications as well as vitamin/supplement use.
**ALLERGIES**: Include medications, foods, and chemicals such as latex.
**Immunizations History:** list current immunization status and address deficiency
**Preventative health History: (** See Table below – Appendix A)
**SOCIAL HISTORY:**
·
**Include** nutrition, exercise, substance use (details of use: caffeine, EtOH, illicit drug use), sexual history/preference, financial problems, legal issues, kids, and history of abuse, including sexual, emotional, or physical.
·
**Employment/Education:** occupation (type), exposure to harmful agents, highest school achievement
**REVIEW OF SYSTEMS:**
· A ROS is a question-seeking inventory by body systems to identify signs and/or symptoms that the patient may be experiencing or has experienced that may or may not correlate with the CC.
*If a + finding is found not related to the cc this may represent an additional problem that will need to be detailed in the HPI.
· Must include any physical complaint(s) by the body system that is relevant to the treatment and management of the current concern(s).
**List only the pertinent body systems specific to the CC.**
·
Remember to include pertinent positive and negative findings when detailing the ROS related to a chief concern (cc).
·
Do not repeat the information provided in HPI
· Use the format below when detailing the ROS
**ROS:**
General:
Eyes:
Ears, nose, mouth & throat:
Cardiovascular:
Respiratory:
Gastrointestinal:
Skin & Breasts:
Musculoskeletal:
Allergic:
Immunologic:
Endocrine:
Hematopoietic/Lymphatic:
Genitourinary:
Neurological:
Psychiatric/Mental Status:
**Objective**
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure. Heart rate (regular or irregular). Respirations. SaO2 (on room air or O2). Temperature. Weight. Height.
*Document the presence of any internal/external devices (IV, Central lines, NGTs, G-tubes, Ostomies, urinary catheters) and dates of placement.
General:
Eyes:
Ears, nose, mouth & throat:
Cardiovascular:
Respiratory:
Gastrointestinal:
Skin & Breasts:
Musculoskeletal:
Allergic:
Immunologic:
Endocrine:
Hematopoietic/Lymphatic:
Genitourinary:
Neurological:
Psychiatric/Mental Status:
**Pertinent Diagnostic Test Results:**
**Assessment (Diagnosis)**
Differential Diagnosis (DDx)
· Include two (2) differential diagnoses you considered but did not select as the final diagnosis. Why were these 2 diagnoses not selected? Support with pertinent positive and negative findings for each differential with an evidence-based guideline(s) (required).
Working or Final Diagnosis:
· Final or working diagnosis (1) (including ICD-10 code)
· Provide a rational explanation supported by evidenced-based guidelines (required). List the pertinent positive and negative symptoms/signs that support your final diagnosis.
**Plan**
Treatment (Tx) Plan: pharmacologic and/or nonpharmacologic
· Pharmacologic -include full prescribing information for each medication(s) ordered
· Refill Provided: Include full prescribing information for each medication(s) refilled and the correlating diagnosis related to the refill.
Patient Education:
· Include specific education related to each medication prescribed.
· Was risk versus benefit of current treatment plan addressed for medication(s) and interventions? Was the patient included in the medical decision making and in agreement with the final plan
· NPs should not be prescribing non-FDA approved medications or medications related to off-label use. If a physician prescribed a non-FDA-approved medication for working diagnosis or recommended off-label use was education provided and was the risk to benefit of the medication(s) addressed in the patient’s education?
Prognosis Good, Fair, or Poor?
· Indicate the patient’s prognosis: Good, Fair, Poor
· Provide support for your selected prognosis
Referral/Follow-up
· Did you recommend follow-up with PCP, or other healthcare professionals?
· When is the subsequent follow-up?
Disposition:
· Indicate the disposition of the patient.
· Was the patient sent home, Emergency room via EMS, etc.
· Include rationale for the follow-up recommendation or referral
Reference(s)
· Include APA formatted references for written assignments.
· Minimum 2 references are required from evidence-based resources.
· Oral assignments should include verbally articulated evidence-based guideline(s) used to prepare the oral presentation.
APPENDIX A
**PREVENTATIVE CARE SCHEDULE (Example – not all-inclusive)**
| | | | |
| — | — | — | — |
| Preventive Care | Date | Result | Referrals Made |
| Pap | | | |
| Mammogram | | | |
| A1C | | | |
| Eye Exam | | | |
| Monofilament Test | | | |
| Urine<br>Microalbumin | | | |
| Diet/Lifestyle Modifications | | | |
| Digital Rectal Exam (DRE) | | | |
| PSA | | | |
| Colonoscopy or FOBT | | | |
| Dexa Scan | | | |
| CXR | | | |
| BNP | | | |
| ECG | | | |
| Echo | | | |
| Stress <br>Test | | | |
| | | | |
| Vaccines | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |