Soap Note 2 hepatic encephalopathy_

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Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C

Soap Note # _2___ Main Diagnosis ___hepatic encephalopathy___________ 

PATIENT INFORMATION

Name:

Age

Gender at Birth: 

Gender Identity

Source

Allergies

Current Medications: 

·  

PMH: 

Immunizations: 

Preventive Care

Surgical History

Family History:

Social History

Sexual Orientation

Nutrition History

Subjective Data:

Chief Complaint

Symptom analysis/HPI:

The patient is … 

Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. ) 

CONSTITUTIONAL

NEUROLOGIC

HEENT

RESPIRATORY

CARDIOVASCULAR

GASTROINTESTINAL

GENITOURINARY

MUSCULOSKELETAL

SKIN

Objective Data:

VITAL SIGNS: 

GENERAL APPREARANCE

NEUROLOGIC:

HEENT: 

CARDIOVASCULAR: 

RESPIRATORY: 

GASTROINTESTINAL: 

MUSKULOSKELETAL:

INTEGUMENTARY: 

ASSESSMENT:

(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data) 

Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.) 

Main Diagnosis

(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)

-

-

-

PLAN:

Labs and Diagnostic Test to be ordered (if applicable)

· - 

· - 

Pharmacological treatment: 

-

Non-Pharmacologic treatment

Education (provide the most relevant ones tailored to your patient)

Follow-ups/Referrals

References (in APA Style)

Examples 

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). 

ISBN 978-0-8261-3424-0

Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010

(25th ed.). Print (The 5-Minute Consult Series).

 Use APA format and must include minimum of 2 Scholarly Citations. 


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