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Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical I

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Miami Regional UniversityDate of Encounter:Preceptor/Clinical Site:Clinical Instructor: Patricio Bidart MSN, APRN, FNP-CSoap Note # ____ Main Diagnosis ______________PATIENT INFORMATIONName:Age:Gender at Birth:Gender Identity:Source:Allergies:Current Medications:·PMH:Immunizations:PreventiveCare:Surgical History:Family History:Social History:Sexual Orientation:Nutrition History:Subjective Data:Chief Complaint:Symptom analysis/HPI:Thepatient is …Review of Systems (ROS) (This section is what the patientsays, therefore should state Pt denies, or Pt states….. )CONSTITUTIONAL:NEUROLOGIC:HEENT:RESPIRATORY:CARDIOVASCULAR:GASTROINTESTINAL:GENITOURINARY:MUSCULOSKELETAL:SKIN:Objective Data:VITAL SIGNS:GENERAL APPREARANCE:NEUROLOGIC:HEENT:CARDIOVASCULAR:RESPIRATORY:GASTROINTESTINAL:MUSKULOSKELETAL:INTEGUMENTARY:

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