Nurse Practitioner Primary Care SOAP Note
Created by
Jennifer Miller
Specialty
Nurse Practitioner
Last edited
10/20/2026
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0 times
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About this template
This template supports efficient SOAP documentation for Nurse Practitioners, covering the patient’s presentation, assessment, planned investigations and treatment, and patient education. It is suited to structured primary care documentation, including chronic condition management and confirmation of the patient’s understanding of the care plan.
Preview template
Sarah Jenkins (DOB: 12/08/1976, MRN: 492-810-44) is a 48-year-old female presenting at 09:15 on 24/10/2023 for evaluation of a 10-day history of worsening facial pressure, purulent nasal discharge, and maxillary toothache. She has been using OTC fluticasone propionate (Flonase®) 50 mcg IN daily and guaifenesin (Mucinex®) 400 mg PO BID for 7 days with minimal relief, followed by a recent worsening of symptoms ("double sickening") over the past 48 hours. Vitals: BP 126/78 mmHg, HR 78 bpm, T 37.8 °C, SpO2 99 % on RA. Exam: NAD, erythematous nasal mucosa with purulent drainage bilaterally, mild bilateral maxillary sinus tenderness to palpation, pharynx clear, lungs CTA bilaterally.
She reports that additional chronic conditions, including HTN and HLD, remain stable on lisinopril 10 mg PO daily and atorvastatin (Lipitor®) 20 mg PO daily.
Assessment and Plan
- Acute bacterial rhinosinusitis (ABRS)
- Differential diagnosis: Viral upper respiratory infection, allergic rhinitis
- Planned investigations: None indicated at this time; clinical diagnosis
- Planned treatment: Start amoxicillin/clavulanic acid (Augmentin®) 875/125 mg PO BID for 5 days; continue fluticasone propionate 50 mcg IN daily; add paracetamol (acetaminophen, Tylenol®) 500 mg PO Q6H PRN pain/fever
- Essential hypertension (HTN)
- Differential diagnosis: Secondary hypertension, white coat hypertension
- Planned investigations: BMP and lipid panel due at next annual physical in 3 months
- Planned treatment: Continue lisinopril 10 mg PO daily
PATIENT EDUCATION
- Advised on completing the full course of antibiotics as prescribed, taking with food to minimize GI upset.
- Recommended nasal saline irrigation BID to assist with mucociliary clearance and symptom relief.
- Reviewed red flag symptoms warranting immediate ER evaluation, including high fever (> 39 °C), vision changes, periorbital edema, severe headache, or neck stiffness.
- Instructed to avoid decongestants containing pseudoephedrine due to underlying HTN.
The patient demonstrated clear comprehension of the medication regimen, potential side effects, and return precautions; questions regarding over-the-counter symptom relief were addressed.
The patient verbalizes understanding and agrees with the plan of care; all questions are answered.
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.