SOAP NOTE TEMPLATE SAMPLE
Miami Regional University
Date of Encounter:
Clinical Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C
Soap Note # ____ Main Diagnosis ______________
Gender at Birth:
The patient is …
Review of Systems (ROS)
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.
Differential diagnosis (minimum 3)
Labs and Diagnostic Test to be ordered (if applicable)
Education (provide the most relevant ones tailored to your patient)
References (in APA Style)
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
(25th ed.). Print (The 5-Minute Consult Series).