Nurse Practitioner Template

SOAP Detailed

A professional Nurse Practitioner template for healthcare professionals.

About this template

The SOAP Detailed template is a comprehensive documentation tool used by Nurse Practitioners to capture detailed patient encounters. This template is ideal for documenting complex cases, as it includes sections for subjective and objective findings, assessments, and treatment plans. It is particularly useful for chronic conditions or when multiple issues are addressed in a single visit. The template ensures thorough documentation, aiding in continuity of care and effective communication among healthcare providers. This template is optimized for use with Heidi, the AI medical scribe, to streamline the documentation process and enhance clinical efficiency.

Preview template

Subjective: - The patient, a 45-year-old female, presents with persistent headaches and dizziness for the past two weeks. She reports a history of migraines but notes that these headaches are different in nature, with a throbbing sensation and sensitivity to light. She denies any recent changes in medication or lifestyle. - Past medical history includes hypertension and a cholecystectomy performed five years ago. - Current medications include Lisinopril 10 mg daily and Ibuprofen as needed for pain. - The patient is a non-smoker and consumes alcohol occasionally. - She has no known allergies. The patient describes the headaches as starting in the morning and worsening throughout the day, with a severity of 7/10. She has tried over-the-counter pain relief with minimal effect. She reports feeling fatigued and has experienced some nausea but no vomiting. The patient manages symptoms by resting in a dark room and using cold compresses, which provide some relief. There have been no recent changes in her symptoms or condition. Review of Systems: - General: Reports fatigue and weight loss of 5 pounds over the last month. - Head: Reports headaches and dizziness. - Eyes: No vision changes reported. - Neurological: Reports occasional tingling in the fingers. Objective: - Vital Signs: - Blood Pressure: 130/85 mmHg - Heart Rate: 78 bpm - Respiratory Rate: 16 breaths/min - Temperature: 98.6°F - Oxygen Saturation: 98% on room air - General Appearance: Alert and oriented, appears fatigued. - HEENT: Mild tenderness on palpation of the temples, no sinus tenderness. - Neurological: Cranial nerves II-XII intact, no focal deficits. Assessment: - Headache Assessment: - Likely diagnosis for Headache: Tension-type headache Diagnostic Tests: - Consider MRI of the brain if symptoms persist or worsen. Treatment Plan: - Initiate trial of Amitriptyline 10 mg at bedtime. - Recommend stress management techniques and regular sleep schedule. Follow-Up: - Instruct patient to contact the clinic if symptoms worsen or do not improve within a week, or if test results indicate further evaluation or treatment is needed.

Subjective: - [describe current issues, reasons for visit, discussion topics, history of presenting complaints etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe past medical history, previous surgeries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention medications and herbal supplements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe social history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [Description of symptoms, onset of symptoms, location of symptoms, duration of symptoms, characteristics of symptoms, alleviating or aggravating factors, timing, and severity] [Current medications and response to treatment] (write this section in narrative form. Write in full sentences and do not include any bullet points) [Any side effects experienced] (write this section in narrative form. Write in full sentences and do not include any bullet points) [Non-pharmacological interventions tried] (write this section in narrative form. Write in full sentences and do not include any bullet points) [Description of any related lifestyle factors] (write this section in narrative form. Write in full sentences and do not include any bullet points) [Patient's experience and management of symptoms] (write this section in narrative form. Write in full sentences and do not include any bullet points) [Any recent changes in symptoms or condition] (write this section in narrative form. Write in full sentences and do not include any bullet points) [Any pertinent positive or pertinent negatives in review of systems] (write this section in narrative form. Write in full sentences and do not include any bullet points) Review of Systems: - [General: weight loss, fever, fatigue, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Skin: rashes, itching, dryness, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Head: headaches, dizziness, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Eyes: vision changes, pain, redness, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Ears: hearing loss, ringing, pain, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Nose: congestion, nosebleeds, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Throat: sore throat, hoarseness, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Neck: lumps, pain, stiffness, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Respiratory: cough, shortness of breath, wheezing, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Cardiovascular: chest pain, palpitations, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Gastrointestinal: nausea, vomiting, diarrhea, constipation, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Genitourinary: frequency, urgency, pain, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Musculoskeletal: joint pain, muscle pain, stiffness, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Neurological: numbness, tingling, weakness, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Psychiatric: depression, anxiety, mood changes, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Endocrine: heat/cold intolerance, excessive thirst, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Hematologic/Lymphatic: easy bruising, swollen glands, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Allergic/Immunologic: allergies, frequent infections, etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave Objective: - Vital Signs: - Blood Pressure: [blood pressure reading] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Heart Rate: [heart rate reading] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Respiratory Rate: [respiratory rate reading] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Temperature: [temperature reading] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Oxygen Saturation: [oxygen saturation reading] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - General Appearance: [general appearance description] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - HEENT: [head, eyes, ears, nose, throat findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Neck: [neck findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Cardiovascular: [cardiovascular findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Respiratory: [respiratory findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Abdomen: [abdominal findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Musculoskeletal: [musculoskeletal findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Neurological: [neurological findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Skin: [skin findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Assessment: - [diagnosis or clinical impression] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [Issue, problem or request 1 (issue, request, topic or condition name only)] Assessment: - [Likely diagnosis for Issue 1 (condition name only)] - [Differential diagnosis for Issue 1 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] Diagnostic Tests: (only include if explicitly mentioned other skip section) - [Investigations and tests planned for Issue 1 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] Treatment Plan: - [Treatment planned for Issue 1 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] - [Relevant referrals for Issue 1 (only include if explicitly mentioned- [Likely diagnosis for Issue 1 (condition name only)] [Issue, problem or request 2 (issue, request, topic or condition name only)] Assessment: - [Likely diagnosis for Issue 2 (condition name only)] - [Differential diagnosis for Issue 2 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] Diagnostic Tests: (only include if explicitly mentioned other skip section) - [Investigations and tests planned for Issue 2 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] Treatment Plan: - [Treatment planned for Issue 2 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] - [Relevant referrals for Issue 2 (only include if explicitly mentioned- [Likely diagnosis for Issue 2 (condition name only)] [Issue, problem or request 3,4,5,etc (issue, request, topic or condition name only)] Assessment: - [Likely diagnosis for Issue 3,4,5,etc (condition name only)] - [Differential diagnosis for Issue 3,4,5,etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] Diagnostic Tests: (only include if explicitly mentioned other skip section) - [Investigations and tests planned for Issue 3,4,5,etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] Treatment Plan: - [Treatment planned for Issue 3,4,5,etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] - [Relevant referrals for Issue 3,4,5 etc (only include if explicitly mentioned- [Likely diagnosis for Issue 3,4,5,etc (condition name only)] Follow-Up: - [Instructions for when to seek emergent follow-up care][Monitoring and follow-up recommendations] (If nothing specific is mentioned then write (“ Instruct patient to contact the clinic if symptoms worsen or do not improve within a week, or if test results indicate further evaluation or treatment is needed.) - [Follow up for any persistent, changing or worsening symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank and remove bullet point)] - [Patient education and understanding of the plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank and remove bullet points)] (Never come up with your own patient details, assessment, diagnosis, interventions, evaluation or plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank)

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