SOAP Note Examples & Documentation Tips: For Nurse Practitioners in Primary Care

Book Synopsis: The intent of this book is to provide multiple formats of SOAP note contents for common clinical visits. The intent of this book is not to replace clinical information. Knowing that clinical guidance can change in accordance with the most recent evidence-based practice, I did not create this book as a medical reference. Rather, this book should be used as a guide to format SOAP note documentation, including tips to streamline the SOAP note writing process, primarily through the use of a custom working template.

Inside:Tips to Streamline the Documentation Process, Keyboard Tips for Efficient Transcription, Using this Book to Create a Template, Clinical SOAP Note Format, Abbreviations in Notes, Referring to time within notes, Physical Exam Narrative, Full SOAP example. Sports Physical, Pediatric Well Visit Notes
Supplemental Lab Result Notes: Sample Lab Sets to Order, Iron deficiency, Hypertriglycerides, Pediatric lipid screening, Hyperlipidemia
SOAP Notes for Common Primary Care Visits:
Gastrointestinal Complaints: Constipation SOAP, Diarrhea Note, Gastroenteritis Note, GERD Note, Hemorrhoid Note, Rectal Bleed SOAP
Dermatology Complaints: General Skin Assessment Guidelines, Cellulitis SOAP, Mole SOAP, Rash SOAP, Acne Education Note, Diaper Rash Note, Eczema Note, Keratosis Pilaris Education, Lice Note, Scabies Note, Tinea Ungium Infection Education, Imbedded Tick Education, Varicose Vein Education
Fatigue and Sleep Health: SOAPs and Sample Blurbs: Fatigue SOAP, Insomnia/Difficulty Sleeping SOAP, OSA Note
Fever and Viral Infections: Fever Note, Mononucleosis SOAP, URI SOAP, Influenza Note
Headache & Migraine: Headache SOAP, Migraine SOAP
Head, Ears, Nose & Throat: Acute Otitis Media SOAP, Acute Otitis Externa Note, Concussion Follow-Up Note, Conjunctivitis SOAP, Cerumen Impaction SOAP, Strep Pharyngitis SOAP, Bronchitis Education Note, Tonsil Stone Education Note
Hypertension: Pre-hypertension Education, New Diagnosis of HTN SOAP, Hypertension follow-up SOAP
Joint Health/Pain: Sample Blurbs: Carpal Tunnel Note, Gout Education, Raynaud Education, Rheumatoid/Autoimmune Workup Note, Chondromalacia/Runner’s Knee Note
Lifestyle Modification & Weight Management: Weight loss education note, Obesity note, Bariatric Surgery Initial Visit SOAP, s/p Bariatric Surgery Follow-Up Note, Pre-Diabetes SOAP, Smoking Cessation SOAP
Mental Health: ADD/ADHD SOAP, ETOH/Alcohol Abuse & Misuse Note, Anxiety Note, Depression Note
Orthopedics & Musculoskeletal: Arthritis SOAP, Ankle pain SOAP, Back Pain Note, Hip Pain Note, De Quervain’s Tenosynovitis Education Note, Knee Pain Education, Myalgia Education, Neck Pain Education, SI Joint Note, Osteopenia Education, Sprain Education, Tennis Elbow Education, Shoulder Pain SOAP, TMJ Note
Pain Management: Acute Back Pain Note, Chronic Back Pain Note, Acute on Chronic Back Pain SOAP, Nonpharmacological Pain Management Noes
Podiatry Sample Blurbs: Ingrain Toenail, Plantar Fasciitis, Plantar Warts
Sexual & Reproductive Health: Amenorrhea SOAP, Abnormal Uterine Bleeding Note, Bacterial Vaginitis Note, Dyspareunia Note, Pregnancy Note, Erectile Dysfunction Note, Genital Herpes Note, STI Exposure SOAP, UTI SOAP, Vaginal Discharge Note, Yeast Infection Note
General Contraceptive Notes, Oral contraceptives, IUD, Nexplanon, Patch, Ring
Sexual Health Screening Notes: Breast Cancer Screening Note & STI Screening Note
Procedure Notes, to include Incision & Drainage Procedure, Nexplanon Insertion, Shave Biopsy, Steroid Injection Procedure, PAP Smear, and Wart Destruction Procedure Read more