Template for Clinical SOAP Note Format (Include title here
The “history” section, use patient’s own words. HPI: include symptom dimensions, chronological narrative of patient’s complains, information obtained from other sources (always identify source if not the patient). Pertinent past medical history. Pertinent review of systems, for example, “Patient has not had any stiffness or loss of motion of other joints.”
Current medications (list with daily dosages).
The physical exam and laboratory data section.
Vital signs including oxygen saturation when indicated. Focuses physical exam. All pertinent labs, x-rays, etc. completed at the visit.
Your assessment of the patient’s problems. Follow the rubrics, list the problems in order of priorities.
Use NANDA website to see all nursing diagnosis https://nurse.org/resources/nursing-diagnosis-guide/
All listed problems need to be supported by findings in subjective and objective areas above.
Write 2 interventions for each problem identified on your assessment
Your diagnostic plan may include tests, procedures, other laboratory studies, consultations, etc.
Your treatment plan should include: patient education, pharmacotherapy if any, other therapeutic procedures.
Most use two or more
Do not use Wikipedia or Google.
Can use Google Scholar and/or Microsoft Academics