Facebook tracking pixel
Back to Templates
Advanced Practice Registered Nurse
25-30 minutes

SOAP (Concerns) for Nurse Practitioners

The s10.ai SOAP (Issues) template is expertly crafted for Nurse Practitioners to streamline the documentation of patient visits, offering a structured approach to summarizing patient presentations, evaluating conditions, and detailing treatment plans. This template ensures comprehensive documentation of patient interactions, including chronic disease management and patient education, enhancing the quality of care. By facilitating clear communication of the care plan, it ensures patients fully comprehend their treatment and have their inquiries addressed. Perfect for primary care environments, this template supports meticulous and organized clinical documentation, encouraging Nurse Practitioners to adopt and implement it for improved patient outcomes.

4,088 uses
4.8/5.0
D
Dr. Jonathan Mitchell
Template Structure

Organized sections for comprehensive clinical documentation

(DO NOT INCLUDE PATIENT EDUCATION IN THIS SECTION- ONLY IN PLAN)
[summarize patient presentation, reason for visit, recent treatments, and current status].
[They report additional chronic conditions remain stable].
Assessment and Plan: (Place each likely diagnosis in numerical order)
- [Likely diagnosis (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Differential diagnosis (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Investigations planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Treatment planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[PATIENT EDUCATION]:
[Bullet point Brief patient education discussed in visit: (May include your own instructions based on patient information and general knowledge)]
[Statement regarding patient's understanding of care plan and questions addressed]
[Patient verbalizes understanding and agrees with plan of care, all questions answered].
Sample Clinical Note

Example of completed documentation using this template

Subjective: The patient, a 45-year-old female, presents with complaints of ongoing headaches over the past two weeks. She describes the headaches as throbbing and accompanied by nausea. She has a history of migraines but mentions that these headaches feel different. Recent treatments include over-the-counter pain relief, which has provided minimal relief. The patient also reports that her chronic hypertension remains stable with current medication.
Objective: Upon examination, the patient appears in mild distress due to pain. Vital signs are within normal limits, except for a slightly elevated blood pressure of 140/90 mmHg. Neurological examination is unremarkable.
Assessment and Plan:
- Likely diagnosis: Tension-type headache
- Differential diagnosis: Migraine, sinusitis
- Investigations planned: MRI of the brain to rule out any structural abnormalities
- Treatment planned: Prescribe amitriptyline for headache prophylaxis and recommend lifestyle modifications including stress management techniques
Patient Education:
- Discussed the importance of maintaining a headache diary to identify potential triggers
- Advised on the benefits of regular exercise and adequate hydration
- Explained the use of prescribed medication and potential side effects
The patient verbalizes understanding and agrees with the plan of care, all questions answered.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline the documentation process for healthcare professionals, ensuring accurate and efficient patient records. By summarizing the patient's presentation, reason for visit, recent treatments, and current status, clinicians can quickly assess the patient's condition and make informed decisions. The template allows for the organization of assessments and plans, including likely diagnoses, differential diagnoses, planned investigations, and treatments, in a structured manner. Additionally, it facilitates effective patient education by providing a dedicated section for discussing key points during the visit. This template enhances clinical workflows, improves patient care, and supports compliance with medical documentation standards. Explore and implement this template to optimize your practice's efficiency and patient outcomes.
Frequently Asked Questions

Common questions about this template and its usage

Ready to transform your practice?

Join thousands of clinicians already using S10.AI to reduce administrative burden and improve patient care.

Cookie Preferences

We use cookies to enhance your browsing experience, analyze site traffic and personalize content.

SOAP (Concerns) for Nurse Practitioners