Soap Note: Acute Myocardial Infarction

Soap Note: Acute Myocardial Infarction

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Soap Note: Acute Myocardial Infarction

Follow the Soap Note Rubric as a guide:

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

Soap Note Rubric:

 

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: 

Soap Note # 1     Main Diagnosis: Acute Myocardial Infarction

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)

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL:

SKIN:

Objective Data:

VITAL SIGNS:

GENERAL APPEARANCE:

NEUROLOGIC:

HEENT:

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:

ASSESSMENT:

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).

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