Nursing Mini SOAP Note

Nursing Mini SOAP Note

Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit as a Word Document. See example template below for required format.

Review the rubric for more information on how your assignment will be graded. Demographic Data

• Age, and gender (must be HIPAA compliant)

Subjective

• Chief Complaint (CC) unless an Annual Physical Exam (APE)
• History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)
• Past Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance as applicable

• Family Hx: As applicable
• Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school,
• Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)

Check tips on how to do your SOAP Note Assignment 

Nursing Mini SOAP Note

Objective

• Vital signs
• Physical findings listed by body systems, not paragraph form Assessment (Diagnosis/ICD10 Code)
• Include all diagnoses that apply for this visit

Plan

• Dx Plan (lab, x-ray)
• Tx Plan: (meds)
• Education, including specific medication teaching points
• Referral/Follow-up
• Health maintenance (including when screenings, immunizations, , are next due):

Nursing Mini SOAP Note

Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit as a Word Document. See example template below for required format.

Review the rubric for more information on how your assignment will be graded. Demographic Data

• Age, and gender (must be HIPAA compliant)

Subjective

• Chief Complaint (CC) unless an Annual Physical Exam (APE)
• History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)
• Past Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance as applicable
• Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
• Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)