Posted: May 1st, 2025

Focused SOAP

52 y/o female coming today for left hip pain. Please fill out attached template completely. Make up information for template to flow effectively.

October 1, 2022
Jessenia Alegria
Registered Nurse
627 SW 95 CT Miami, FL 33174
Jessal@baptisthealth.net
Guadalupe Almaguer- West Kendall Baptist Hospital ICU
Dear Ms. Lupe and Supervisors,
Please accept this letter as formal notification that I am resigning from my position as Registered
Nurse with West Kendall Baptist ICU. My last day will be October 15, 2022.
I appreciate the opportunities for my professional development that you have provided me over the
past year. Unfortunately, this past year has been very challenging in my personal life and management
has stayed in touch along the way throughout my recovery and I would forever appreciate you all. I have
enjoyed my tenure at WKBH ICU and in particular feel honored to have been trained and been part of
such a supportive team. I am incredibly grateful for working along such an amazing team that provided
and maintained patient safety first priority and allowed me to grow at my own pace with all the
phenomenal resources. There is still so much for me to learned but yet I have developed as a registered
nurse in compared to last year, which I will certainly take with me throughout my career.
Thank you for all your guidance. I wish the company continued success and you all the best. I hope to
stay in touch.
Sincerely,
Jessenia Alegria
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
o
o
Patient age and gender identity
MUST BE HIPAA compliant
Subjective
Chief Complaint (CC)
O
O
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)
O Briefly describe the general state of health prior to the problem.
O Are Activities of Daily Living (ADL) impacted by the current problem?
O
PAST MEDICAL HISTORY:
O List current and past medical diagnoses
PAST SURGICAL HISTORY:
O List all past surgeries
FAMILY HISTORY:
O Include medical/psychiatric problems to include 3 generations (parents,
grandparents, siblings, or direct relatives.
CURRENT MEDICATIONS:
O 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.
O Employment/Education: occupation (type), exposure to harmful agents,
highest school achievement
O
REVIEW OF SYSTEMS:
O 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.
O 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.
O Remember to include pertinent positive and negative findings when detailing
the ROS related to a chief concern (cc).
O Do not repeat the information provided in HPI
O 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)
O
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 evidencebased guideline(s) (required).
Working or Final Diagnosis:
O Final or working diagnosis (1) (including ICD-10 code)
O 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
O Refill Provided: Include full prescribing information for each medication(s)
refilled and the correlating diagnosis related to the refill.
O
Patient Education:
O Include specific education related to each medication prescribed.
O 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
O 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?
O Indicate the patient’s prognosis: Good, Fair, Poor
O Provide support for your selected prognosis
Referral/Follow-up
O Did you recommend follow-up with PCP, or other healthcare professionals?
O When is the subsequent follow-up?
Disposition:
O Indicate the disposition of the patient.
O
O
Was the patient sent home, Emergency room via EMS, etc.
Include rationale for the follow-up recommendation or referral
Reference(s)
o Include APA formatted references for written assignments.
o Minimum 2 references are required from evidence-based resources.
o 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
Pap
Mammogram
A1C
Eye Exam
Monofilament
Test
Urine
Microalbumin
Diet/Lifestyle
Modifications
Digital Rectal
Exam (DRE)
PSA
Colonoscopy
or FOBT
Dexa Scan
CXR
BNP
ECG
Echo
Stress
Test
Vaccines
Date
Result
Referrals Made