Assignment Prompt & Instructions
Create a SOAP notes, the template and the case is attached, using 3 or more references, No AI, plagiarism less than 20 %
– ## AsthmaExacerbation.docx
– ## SOAP_NOTE_Template_20254.docx
**## AsthmaExacerbation.docx**
**Asthma Exacerbation**
**Date of Encounter:** 09/01/2025
**Age/Sex:** 29-year-old Female
**Race:** Hispanic
**Insurance:** PPO
**Referral:** No referral
**Reason for Visit:** New Consult
**Chief Complaint:** Shortness of breath, wheezing, and cough for 2 days
**Type of H&P:** Focused
**Type of Decision-Making:** Moderate
**Time with Patient:** 35 minutes
**Consult with Preceptor:** 10 minutes
**Social Problems Addressed:** Education/Language, Safety
**Medications:** Albuterol 90 mcg inhaler PRN, Prednisone 40 mg daily x5 days
**Adherence Issues:** None reported
**ICD-10 Codes:**
· J45.901 – Unspecified asthma with (acute) exacerbation
**CPT® Billing Codes:**
· 99213 – Office/outpatient visit, established patient
**Clinical Notes:**
Patient presents with SOB, wheezing, and cough for 2 days. O₂ sat 94%, scattered expiratory wheezes. Nebulized albuterol given in office with improvement. Prescribed short course of oral steroids and advised inhaler use every 4–6 hrs as needed. Patient educated on trigger avoidance and follow-up in 1 week.
**## SOAP_NOTE_Template_20254.docx**
**(Student Name)**
**Miami Regional University**
**Date of Encounter:**
**Preceptor/Clinical Site:**
**Clinical Instructor:**
**Soap Note # ____ Main Diagnosis ______________**
**PATIENT INFORMATION**
**Name**:
**Age**:
**Gender at Birth:**
**Gender Identity**:
**Source**:
**Allergies**:
**Current Medications: (including OTC and vitamins)**
·
**PMH:**
**Immunizations:**
**Preventive Care**:
**Preventive Screenings: (for results already obtained before this encounter)**
**- Pap smear: ______**
**- Mammogram: ______**
**- Colonoscopy: ______**
**- Lipid panel: ______**
**- A1C: ______**
**- STI screen: ______**
**- Depression screen (PHQ-9): ______**
**Surgical History**:
**Family History**:
**Social History**:
**Sexual Orientation**:
**Nutrition History**:
**SUBJECTIVE DATE**
**Chief Complaint** **(which must be stated between “__”)**
**Symptom analysis/HPI:**
**Clinical Tools Used (if applicable), otherwise state N/A**
**- PHQ-9: ___ /27**
**- GAD-7: ___ /21**
**- AUDIT-C / DAST:**
**Review of Systems (ROS) (This section is what the patient says, therefore it should state “Pt denies… or Pt states…”)**
**CONSTITUTIONAL**:
**NEUROLOGIC**:
**HEENT**:
**RESPIRATORY**:
**CARDIOVASCULAR**:
**GASTROINTESTINAL**:
**GENITOURINARY**:
**MUSCULOSKELETAL**:
**SKIN**:
**OBJECTIVE DATA**
**VITAL SIGNS:** **LABS / DIAGNOSTICS REVIEWED (if available):**
**- CBC:**
**- Lipid Panel:**
**- A1C:**
**- EKG:**
**- Imaging (if done):**
**GENERAL APPREARANCE**:
**NEUROLOGIC:**
**HEENT:**
**CARDIOVASCULAR:**
**RESPIRATORY:**
**GASTROINTESTINAL:**
**MUSKULOSKELETAL:**
**INTEGUMENTARY:**
**ASSESSMENT**
**Red Flags / Reasons for Escalation:**
**- [ ] None noted**
**- [ ] Positive suicidal ideation**
**- [ ] Unstable vital signs**
**- [ ] Abnormal exam requiring urgent referral**
**Clinical Note**
**(In a paragraph you should state “your encounter with your patient and your findings (including subjective and objective data)**
**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) along with the rationale behind them.**
**_(why you decide to include these differential diagnosis for this patient? What part of your assessment supports them?)_**
**-**
**-**
**-**
**PLAN**
**Labs and Diagnostic Test to be ordered (if applicable)**
· –
· –
**Pharmacological treatment:**
**-**
**Non-Pharmacologic treatment**:
**Education (provide the most relevant ones – tailored to this specific patient**
**_– not in general)_**
**Follow-ups/Referrals**
**Visit Complexity / CPT Code: _______**
**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).
## image1.png
**## SOAP_NOTE_Template_20254.docx**
**(Student Name)**
**Miami Regional University**
**Date of Encounter:**
**Preceptor/Clinical Site:**
**Clinical Instructor:**
**Soap Note # ____ Main Diagnosis ______________**
**PATIENT INFORMATION**
**Name**:
**Age**:
**Gender at Birth:**
**Gender Identity**:
**Source**:
**Allergies**:
**Current Medications: (including OTC and vitamins)**
·
**PMH:**
**Immunizations:**
**Preventive Care**:
**Preventive Screenings: (for results already obtained before this encounter)**
**- Pap smear: ______**
**- Mammogram: ______**
**- Colonoscopy: ______**
**- Lipid panel: ______**
**- A1C: ______**
**- STI screen: ______**
**- Depression screen (PHQ-9): ______**
**Surgical History**:
**Family History**:
**Social History**:
**Sexual Orientation**:
**Nutrition History**:
**SUBJECTIVE DATE**
**Chief Complaint** **(which must be stated between “__”)**
**Symptom analysis/HPI:**
**Clinical Tools Used (if applicable), otherwise state N/A**
**- PHQ-9: ___ /27**
**- GAD-7: ___ /21**
**- AUDIT-C / DAST:**
**Review of Systems (ROS) (This section is what the patient says, therefore it should state “Pt denies… or Pt states…”)**
**CONSTITUTIONAL**:
**NEUROLOGIC**:
**HEENT**:
**RESPIRATORY**:
**CARDIOVASCULAR**:
**GASTROINTESTINAL**:
**GENITOURINARY**:
**MUSCULOSKELETAL**:
**SKIN**:
**OBJECTIVE DATA**
**VITAL SIGNS:** **LABS / DIAGNOSTICS REVIEWED (if available):**
**- CBC:**
**- Lipid Panel:**
**- A1C:**
**- EKG:**
**- Imaging (if done):**
**GENERAL APPREARANCE**:
**NEUROLOGIC:**
**HEENT:**
**CARDIOVASCULAR:**
**RESPIRATORY:**
**GASTROINTESTINAL:**
**MUSKULOSKELETAL:**
**INTEGUMENTARY:**
**ASSESSMENT**
**Red Flags / Reasons for Escalation:**
**- [ ] None noted**
**- [ ] Positive suicidal ideation**
**- [ ] Unstable vital signs**
**- [ ] Abnormal exam requiring urgent referral**
**Clinical Note**
**(In a paragraph you should state “your encounter with your patient and your findings (including subjective and objective data)**
**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) along with the rationale behind them.**
**_(why you decide to include these differential diagnosis for this patient? What part of your assessment supports them?)_**
**-**
**-**
**-**
**PLAN**
**Labs and Diagnostic Test to be ordered (if applicable)**
· –
· –
**Pharmacological treatment:**
**-**
**Non-Pharmacologic treatment**:
**Education (provide the most relevant ones – tailored to this specific patient**
**_– not in general)_**
**Follow-ups/Referrals**
**Visit Complexity / CPT Code: _______**
**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).
## image1.png
**## AsthmaExacerbation.docx**
**Asthma Exacerbation**
**Date of Encounter:** 09/01/2025
**Age/Sex:** 29-year-old Female
**Race:** Hispanic
**Insurance:** PPO
**Referral:** No referral
**Reason for Visit:** New Consult
**Chief Complaint:** Shortness of breath, wheezing, and cough for 2 days
**Type of H&P:** Focused
**Type of Decision-Making:** Moderate
**Time with Patient:** 35 minutes
**Consult with Preceptor:** 10 minutes
**Social Problems Addressed:** Education/Language, Safety
**Medications:** Albuterol 90 mcg inhaler PRN, Prednisone 40 mg daily x5 days
**Adherence Issues:** None reported
**ICD-10 Codes:**
· J45.901 – Unspecified asthma with (acute) exacerbation
**CPT® Billing Codes:**
· 99213 – Office/outpatient visit, established patient
**Clinical Notes:**
Patient presents with SOB, wheezing, and cough for 2 days. O₂ sat 94%, scattered expiratory wheezes. Nebulized albuterol given in office with improvement. Prescribed short course of oral steroids and advised inhaler use every 4–6 hrs as needed. Patient educated on trigger avoidance and follow-up in 1 week.
**## SOAP_NOTE_Template_20254.docx**
**(Student Name)**
**Miami Regional University**
**Date of Encounter:**
**Preceptor/Clinical Site:**
**Clinical Instructor:**
**Soap Note # ____ Main Diagnosis ______________**
**PATIENT INFORMATION**
**Name**:
**Age**:
**Gender at Birth:**
**Gender Identity**:
**Source**:
**Allergies**:
**Current Medications: (including OTC and vitamins)**
·
**PMH:**
**Immunizations:**
**Preventive Care**:
**Preventive Screenings: (for results already obtained before this encounter)**
**- Pap smear: ______**
**- Mammogram: ______**
**- Colonoscopy: ______**
**- Lipid panel: ______**
**- A1C: ______**
**- STI screen: ______**
**- Depression screen (PHQ-9): ______**
**Surgical History**:
**Family History**:
**Social History**:
**Sexual Orientation**:
**Nutrition History**:
**SUBJECTIVE DATE**
**Chief Complaint** **(which must be stated between “__”)**
**Symptom analysis/HPI:**
**Clinical Tools Used (if applicable), otherwise state N/A**
**- PHQ-9: ___ /27**
**- GAD-7: ___ /21**
**- AUDIT-C / DAST:**
**Review of Systems (ROS) (This section is what the patient says, therefore it should state “Pt denies… or Pt states…”)**
**CONSTITUTIONAL**:
**NEUROLOGIC**:
**HEENT**:
**RESPIRATORY**:
**CARDIOVASCULAR**:
**GASTROINTESTINAL**:
**GENITOURINARY**:
**MUSCULOSKELETAL**:
**SKIN**:
**OBJECTIVE DATA**
**VITAL SIGNS:** **LABS / DIAGNOSTICS REVIEWED (if available):**
**- CBC:**
**- Lipid Panel:**
**- A1C:**
**- EKG:**
**- Imaging (if done):**
**GENERAL APPREARANCE**:
**NEUROLOGIC:**
**HEENT:**
**CARDIOVASCULAR:**
**RESPIRATORY:**
**GASTROINTESTINAL:**
**MUSKULOSKELETAL:**
**INTEGUMENTARY:**
**ASSESSMENT**
**Red Flags / Reasons for Escalation:**
**- [ ] None noted**
**- [ ] Positive suicidal ideation**
**- [ ] Unstable vital signs**
**- [ ] Abnormal exam requiring urgent referral**
**Clinical Note**
**(In a paragraph you should state “your encounter with your patient and your findings (including subjective and objective data)**
**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) along with the rationale behind them.**
**_(why you decide to include these differential diagnosis for this patient? What part of your assessment supports them?)_**
**-**
**-**
**-**
**PLAN**
**Labs and Diagnostic Test to be ordered (if applicable)**
· –
· –
**Pharmacological treatment:**
**-**
**Non-Pharmacologic treatment**:
**Education (provide the most relevant ones – tailored to this specific patient**
**_– not in general)_**
**Follow-ups/Referrals**
**Visit Complexity / CPT Code: _______**
**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).
## image1.png
**## AsthmaExacerbation.docx**
**Asthma Exacerbation**
**Date of Encounter:** 09/01/2025
**Age/Sex:** 29-year-old Female
**Race:** Hispanic
**Insurance:** PPO
**Referral:** No referral
**Reason for Visit:** New Consult
**Chief Complaint:** Shortness of breath, wheezing, and cough for 2 days
**Type of H&P:** Focused
**Type of Decision-Making:** Moderate
**Time with Patient:** 35 minutes
**Consult with Preceptor:** 10 minutes
**Social Problems Addressed:** Education/Language, Safety
**Medications:** Albuterol 90 mcg inhaler PRN, Prednisone 40 mg daily x5 days
**Adherence Issues:** None reported
**ICD-10 Codes:**
· J45.901 – Unspecified asthma with (acute) exacerbation
**CPT® Billing Codes:**
· 99213 – Office/outpatient visit, established patient
**Clinical Notes:**
Patient presents with SOB, wheezing, and cough for 2 days. O₂ sat 94%, scattered expiratory wheezes. Nebulized albuterol given in office with improvement. Prescribed short course of oral steroids and advised inhaler use every 4–6 hrs as needed. Patient educated on trigger avoidance and follow-up in 1 week.
**## SOAP_NOTE_Template_20254.docx**
**(Student Name)**
**Miami Regional University**
**Date of Encounter:**
**Preceptor/Clinical Site:**
**Clinical Instructor:**
**Soap Note # ____ Main Diagnosis ______________**
**PATIENT INFORMATION**
**Name**:
**Age**:
**Gender at Birth:**
**Gender Identity**:
**Source**:
**Allergies**:
**Current Medications: (including OTC and vitamins)**
·
**PMH:**
**Immunizations:**
**Preventive Care**:
**Preventive Screenings: (for results already obtained before this encounter)**
**- Pap smear: ______**
**- Mammogram: ______**
**- Colonoscopy: ______**
**- Lipid panel: ______**
**- A1C: ______**
**- STI screen: ______**
**- Depression screen (PHQ-9): ______**
**Surgical History**:
**Family History**:
**Social History**:
**Sexual Orientation**:
**Nutrition History**:
**SUBJECTIVE DATE**
**Chief Complaint** **(which must be stated between “__”)**
**Symptom analysis/HPI:**
**Clinical Tools Used (if applicable), otherwise state N/A**
**- PHQ-9: ___ /27**
**- GAD-7: ___ /21**
**- AUDIT-C / DAST:**
**Review of Systems (ROS) (This section is what the patient says, therefore it should state “Pt denies… or Pt states…”)**
**CONSTITUTIONAL**:
**NEUROLOGIC**:
**HEENT**:
**RESPIRATORY**:
**CARDIOVASCULAR**:
**GASTROINTESTINAL**:
**GENITOURINARY**:
**MUSCULOSKELETAL**:
**SKIN**:
**OBJECTIVE DATA**
**VITAL SIGNS:** **LABS / DIAGNOSTICS REVIEWED (if available):**
**- CBC:**
**- Lipid Panel:**
**- A1C:**
**- EKG:**
**- Imaging (if done):**
**GENERAL APPREARANCE**:
**NEUROLOGIC:**
**HEENT:**
**CARDIOVASCULAR:**
**RESPIRATORY:**
**GASTROINTESTINAL:**
**MUSKULOSKELETAL:**
**INTEGUMENTARY:**
**ASSESSMENT**
**Red Flags / Reasons for Escalation:**
**- [ ] None noted**
**- [ ] Positive suicidal ideation**
**- [ ] Unstable vital signs**
**- [ ] Abnormal exam requiring urgent referral**
**Clinical Note**
**(In a paragraph you should state “your encounter with your patient and your findings (including subjective and objective data)**
**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) along with the rationale behind them.**
**_(why you decide to include these differential diagnosis for this patient? What part of your assessment supports them?)_**
**-**
**-**
**-**
**PLAN**
**Labs and Diagnostic Test to be ordered (if applicable)**
· –
· –
**Pharmacological treatment:**
**-**
**Non-Pharmacologic treatment**:
**Education (provide the most relevant ones – tailored to this specific patient**
**_– not in general)_**
**Follow-ups/Referrals**
**Visit Complexity / CPT Code: _______**
**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).
## image1.png
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