Academic Soap Note
Academic clinical SOAP 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.
This assignment uses a template. Refer to the “Academic SOAP Note Template,” located on the Student Success Center page under the AGACNP tab.
Develop a hospital follow-up progress SOAP note based on a clinical patient from your clinical/practicum setting. In your assessment, provide the following:
- A one-sentence description of the primary working diagnosis, pending differential diagnoses, and the context or service in which the patient is being seen.
- A one or two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures. Include how many days the patient has been hospitalized, if applicable.
- List of at least five systems affected by the working diagnosis. Provide two positive or negative effects that the working diagnosis has on each system.
- List of at least five systems examined within the past 24 hours. Provide at least two pertinent positive or negative findings relevant to each system examined and include a full set of vital signs.
- List of all admission diagnostics conducted for this visit or conducted within the past 24 hours.
- List of all pertinent acute and chronic diagnoses in order of priority using ICD-10. Identify any differential diagnoses being eliminated.
- Treatment plan that corresponds with the diagnosis. Provide information on admission type, types of diagnostics, any prescribed medications and dosages, and any relevant consults or follow-up procedures needed.
- Discussion of any relevant ethical, legal, or geriatric-specific considerations.
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 familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite Technical Support Articles is located in Class Resources if you need assistance.
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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