NURSE PRACTITIONER SOAP NOTE

Patient: [Name]
Date of birth: [Date]
Date of visit: [Date]
Source of history: [Patient, parent, or caregiver, and how reliable]
Nurse practitioner: [Name, credentials]

SUBJECTIVE
Chief complaint: [In the patient's words]
History of present illness: [Onset, location, duration, character, aggravating and relieving factors, radiation, timing, severity]
Pertinent positives: [Symptoms present that support the leading diagnosis]
Pertinent negatives: [Symptoms absent that make other diagnoses and red flags less likely]
Past medical history: [Conditions, surgeries, hospital stays]
Medications: [Prescription, over-the-counter, and supplements, with doses]
Allergies: [Drug, food, and other allergies, with the reaction to each]
Social history: [Tobacco, alcohol, substances, work, living situation, and sexual history if relevant]
Review of systems: [Systems reviewed, with pertinent findings]

OBJECTIVE
Vital signs: [BP, HR, RR, temperature, SpO2, weight]
Focused examination: [General appearance and the systems related to the complaint]
Point-of-care tests: [Urine dipstick, rapid tests, pregnancy test, or glucose, with results]

ASSESSMENT
Primary diagnosis: [Diagnosis, with the history and exam findings that support it]
Differential 1: [Alternative diagnosis, and why it is more or less likely]
Differential 2: [Alternative diagnosis, and why it is more or less likely]
Differential 3: [Alternative diagnosis, and why it is more or less likely]

PLAN
Diagnostics: [Labs, cultures, or imaging ordered and why, or why none are needed]
Therapeutics: [Medications and non-drug treatment, and the guideline followed]
Education: [What was taught, and the patient's understanding]
Referral or consultation: [Collaborating physician, specialist, or other service, if any]
Follow-up: [When to return, and the warning signs that mean returning sooner]

PRESCRIBING DETAILS
Prescription: [Drug, strength, dose, route, frequency, duration, quantity, and refills]
Checks: [Allergies, interactions, pregnancy or lactation, kidney function, and weight-based dosing reviewed]

Signed: [Nurse practitioner name, credentials, date and time]