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Academic SOAP Note Template
Reason for Follow-Up: A one-sentence description of the primary working diagnosis that
identifies admit date or hospital day of visit, pending differential diagnoses, and context or
service in which the patient is being seen is provided and includes supporting details.
Clinical Course Summary: A one-to-two paragraph description of the current illness or hospital
stay, including pertinent diagnostic findings or procedures and the number of days since the
patient has been hospitalized, is complete with supporting documentation. (This is not the HPI.)
Review of systems: Review of the symptoms the patient or his/her family explains, organized by
system. Five systems affected by the working diagnosis, along with two positive or negative
effects of the diagnosis on each system, are provided with thorough details and support. Refer to
the H&P template for ROS options.
Physical Exam: Five systems examined within the last 24 hours, including two positive or
negative findings relevant to each system and a full set of vital signs, are provided with thorough
details and support. Refer to the H&P template for ROS options.
Laboratory and Radiology Results: List pertinent data available when seeing the patient
pertinent to the reasons for follow-up. Include normal and abnormal results and identify the
abnormalities.
Assessment: (Provide three references) Identification of all acute and chronic diagnoses in
order of ICD-10 priority and any differential diagnoses being eliminated are provided with
thorough details and support.
• Differential diagnoses: What is pending to be ruled in or ruled out? A differential is only
needed if there is a sign/symptom for which you have not identified a diagnosis.
• Acute and chronic medical conditions: Include the ICD-10 diagnosis code (look in
Lopes Activity Tracker).
Treatment Plan: (Provide three references) A treatment plan that corresponds with the
diagnosis and includes admission type, diagnostics, medications and dosages, and any consults
or follow-up procedures needed is provided with thorough details and support.
What orders are you starting? What medications (include dose and frequency of new meds or
changes in dose of existing meds)? What consults? Education topics? Discharge plan?
Geriatric Considerations: Based on the age, address any differences in the treatment if the
patient were younger or older.
References: Use three references listed in APA format.
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Academic Clinical History and Physical Note – Rubric
Collapse All Academic Clinical History And Physical Note – RubricCollapse All
History and Physical Note
10 points
Criteria Description
History and Physical Note (Chief Complaint, HPI, Patient History, Home Medications, Review of Systems, Vital Signs, Physical Exam, Test Results)
5. Target
10 points
The history and physical note is thoroughly explored and clearly explained with relevant details and support.
4. Acceptable
9 points
The history and physical note is provided with appropriate details and support.
3. Approaching
8 points
The history and physical note is present, but only minimal detail or support is provided.
2. Insufficient
5 points
The history and physical note is incomplete or otherwise deficient.
1. Unsatisfactory
0 points
The history and physical note is not included.
Assessment and Clinical Impressions
10 points
Criteria Description
Assessment and Clinical Impressions (Identification of Three Differential Diagnoses, List of Acute and Chronic Diagnoses, List of Diagnoses and Conditions in Priority Order)
5. Target
10 points
The assessment and clinical impressions are thoroughly explored and clearly explained with relevant details and support.
4. Acceptable
9 points
The assessment and clinical impressions are provided with appropriate details and support.
3. Approaching
8 points
The assessment and clinical impressions are present, but only minimal detail or support is provided.
2. Insufficient
5 points
The assessment and clinical impressions are incomplete or otherwise deficient.
1. Unsatisfactory
0 points
The assessment and clinical impressions are not included.
Plan and Criteria Incorporation
10 points
Criteria Description
Plan Component Management and Criteria Incorporation (Interventions, Disposition, Expected Outcomes, Health Education, and Case Summary)
5. Target
10 points
The plan component management and plan criteria incorporation are thoroughly explored and clearly explained with relevant details and support.
4. Acceptable
9 points
The plan component management and plan criteria incorporation are provided with appropriate details and support.
3. Approaching
8 points
The plan component management and plan criteria incorporation are present, but only minimal detail or support is provided.
2. Insufficient
5 points
The plan component management and plan criteria incorporation are incomplete or otherwise deficient.
1. Unsatisfactory
0 points
The plan component
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Assessment Description
Academic clinical history and physical notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating evidence-based plans of care.
Complete an academic clinical history and physical note based on a patient seen during clinical/practicum. In your assessment, provide the following:
History and Physical Note
1. Chief complaint/reason for admission/visit/consult.
2. HPI for the H&P or consult notes.
3. Medical, surgical, family, social, and allergy history.
4. Home medications, including dosages, route, frequency, and current medications, if a consultation note.
5. Review of systems with all body systems for H&P or consult notes. Review of systems is what the patient or family/friends tell you (by body system).
6. Vital signs and weight.
7. Physical exam with a complete head-to-toe evaluation. Include pertinent positives and negatives based on findings from head-to-toe exam.
8. Lab/Imaging/Diagnostic test results (including date).
Assessment and Clinical Impressions
1. Identify at least three differential diagnoses based upon the chief complaint, ROS, assessment, or abnormal diagnostic tools with rationale.
2. Include a complete list of all diagnoses that are both acute and chronic.
3. List the differential diagnoses and chronic conditions in order of priority.
Plan Component Management and Plan Criteria Incorporation
1. Select appropriate diagnostic and therapeutic interventions based on efficacy, safety, cost, and acceptability. Provide rationale.
2. Discuss disposition and expected outcomes.
3. Identify and address health education, health promotion, and disease prevention.
4. Provide a case summary with ethical, legal, and geriatric considerations. Compare treatment options specific to the geriatric population to nongeriatric adult populations. Consider potential issues, even if they are not evident.
General Requirements
This assignment uses a template. Please refer to the “History and Physical Note Template,” located on the Student Success Center page under the AGACNP tab.
Incorporate at least three peer-reviewed articles in the assessment or plan.
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become famil
ANP- 650
Academic Clinical History and physical Note
Student Name: Theresa Davis-Bates Date: 12-10-2019
PATIENT PROFILE
Patient Initials: B. M.
DOB: 10-18-1927
Sex: Female
Race: Hispanic
Marital Status: widowed
Admit Date: 12-06-2019
Allergies: NKDA
Chief Complaint: Dizziness, syncope
History of Present Illness:
This is a 92-year-old Hispanic female who was brought into ER with CC of dizziness and syncope. She was washing dishes
at her nephew’s birthday party when she fell. Patient reports the dizziness has been going on for a year, but this is the first
time she has fallen and blacked out for a second. Patient reports she woke up when she hit her head. Patient denies any
nausea, vomiting, headaches, chest pain, or recent ear infections. She also reports her blood pressure has been elevated, and
when she takes her medication, standing makes her dizzy. I had patient stand as if she was going to the bathroom, and she
became dizzy right away. Patient also reports bright red blood in stool per rectum with history of hemorrhoids. Reports
history of chronic constipation. Denies abdominal pain or discomfort, no loose stools. HGB stable-11.3. Patient has been
hospitalized for severe constipation in the past.
Past Medical History:
Type 2 diabetes Mellitus non-insulin dependent
Hypertension
Hyperlipidemia
COPD
Chronic constipation
Hemorrhoids
Surgical Medical History:
Right leg surgery: Pt does not know what type of surgery
Bladder lift
Medications:
ProAir 90mcg/inh 1 puff inhaled orally BID
Atorvastatin 20mg 1 tab PO daily
Benazepril 10mg 1 tab PO BID
Lactulose 10g/15ml PO 30ml BID PRN- Constipation
Meclizine 25mg 1 tab PO Q8h as needed- dizziness
Pantoprazole 40mg 1 tab PO daily
Psyllium 3.4g/7g oral powder daily
Social/Personal History:
Patient lives with sister and family. Sister is caregiver.
Widowed.
Denies smoking, recreational drug use, or use of alcohol.
DNR status
Family History:
Mother and brother: Diabetes
Unknown if anyone had CAD or cancer
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ANP 650 Clinical History and Physical Note
Review of Systems:
Constitutional: Denies fever/chills, weight gain or loss, or fatigue
Head: Positive head pain from fall, Denies lightheadedness, confusion
Eyes: Denies vision changes or blurriness
ENT: Positive hard of hearing and vertigo. Denies tinnitus, nasal drainage or stuffiness, denies any sore throat or
swallowing issues
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