WGU D124 FNP OSCE Midterm SOAP Note
Complete Patient Assessment Report
Student Revision Practice Pack
Included SOAP documentation framework, blank practice template, eight completed primary
care cases, clinical reasoning checks, safety-netting, preventive care reminders, and
references.
Formatting Structured table layout modeled on the supplied revision screenshots, with blue section
headers and highlighted assessment/education fields.
Use For student revision and OSCE practice only. It is not official WGU course material and
is not a substitute for faculty instructions, local policy, or patient-specific clinical
judgment.
Core Principle
Document only what was assessed, distinguish patient-reported information from objective findings, and
make the assessment and plan traceable to the history and examination.
Student revision resource - not official course material Page 1
, How to Use This Revision Pack
OSCE WORKFLOW
1. Introduce and verify Confirm identity, role, reason for visit, consent, and immediate safety.
2. Focus the history Use a structured HPI and screen for red flags, medications, allergies, relevant history, and social
determinants.
3. Perform a targeted Start with general appearance and vital signs, then complete a focused system examination.
exam
4. Build the assessment State the most likely diagnosis and at least two defensible alternatives. Explain why each is more or less
likely.
5. Create a safe plan Include tests when indicated, treatment, education, prevention, follow-up, and escalation instructions.
6. Document clearly Use concise, objective language; avoid unsupported normal findings or copy-forward errors.
REVISION RULES
Do Use the patient narrative, objective findings, and current evidence to support the plan.
Do Include negative findings that directly address dangerous alternatives.
Do Use safety-net instructions that are specific and understandable.
Avoid Inventing findings, copying irrelevant full-system examinations, or treating a test result without clinical context.
Avoid Using this revision resource as a prescribing guide for real patients.
Revision Tip: In a timed OSCE, say your red-flag questions aloud. Examiners cannot score clinical reasoning that is never
demonstrated.
Student revision resource - not official course material Page 2
, SOAP Documentation Framework
S - Subjective Chief complaint in the patient's words; HPI; medications; allergies; medical, surgical, family, and social history;
targeted review of systems.
O - Objective Vital signs, general appearance, focused physical examination, and available diagnostic results. Record only
what was observed or measured.
A - Assessment Primary diagnosis plus prioritized differential diagnoses. Link each conclusion to supporting and opposing
evidence.
P - Plan Diagnostics, medication and nonmedication management, education, preventive care, referrals, follow-up, and
specific return precautions.
HPI ORGANIZATION
Element Questions to ask
Onset / Context When did it begin? What was happening at the time?
Location / Radiation Where is it? Does it spread?
Duration / Timing Constant or intermittent? Pattern? Progression?
Character / Severity How does it feel? Severity and functional effect?
Aggravating / Relieving What worsens or improves it? Treatments tried?
Associated symptoms What important positives and negatives help separate the differential diagnoses?
DOCUMENTATION QUALITY CHECK
Check Question
Consistency Do the assessment and plan match the history, vital signs, and exam?
Specificity Are diagnoses and return precautions clear rather than vague?
Safety Were urgent alternatives, contraindications, pregnancy status, and medication risks considered?
Follow-up Is timing defined and linked to the condition or treatment change?
Student revision resource - not official course material Page 3
Complete Patient Assessment Report
Student Revision Practice Pack
Included SOAP documentation framework, blank practice template, eight completed primary
care cases, clinical reasoning checks, safety-netting, preventive care reminders, and
references.
Formatting Structured table layout modeled on the supplied revision screenshots, with blue section
headers and highlighted assessment/education fields.
Use For student revision and OSCE practice only. It is not official WGU course material and
is not a substitute for faculty instructions, local policy, or patient-specific clinical
judgment.
Core Principle
Document only what was assessed, distinguish patient-reported information from objective findings, and
make the assessment and plan traceable to the history and examination.
Student revision resource - not official course material Page 1
, How to Use This Revision Pack
OSCE WORKFLOW
1. Introduce and verify Confirm identity, role, reason for visit, consent, and immediate safety.
2. Focus the history Use a structured HPI and screen for red flags, medications, allergies, relevant history, and social
determinants.
3. Perform a targeted Start with general appearance and vital signs, then complete a focused system examination.
exam
4. Build the assessment State the most likely diagnosis and at least two defensible alternatives. Explain why each is more or less
likely.
5. Create a safe plan Include tests when indicated, treatment, education, prevention, follow-up, and escalation instructions.
6. Document clearly Use concise, objective language; avoid unsupported normal findings or copy-forward errors.
REVISION RULES
Do Use the patient narrative, objective findings, and current evidence to support the plan.
Do Include negative findings that directly address dangerous alternatives.
Do Use safety-net instructions that are specific and understandable.
Avoid Inventing findings, copying irrelevant full-system examinations, or treating a test result without clinical context.
Avoid Using this revision resource as a prescribing guide for real patients.
Revision Tip: In a timed OSCE, say your red-flag questions aloud. Examiners cannot score clinical reasoning that is never
demonstrated.
Student revision resource - not official course material Page 2
, SOAP Documentation Framework
S - Subjective Chief complaint in the patient's words; HPI; medications; allergies; medical, surgical, family, and social history;
targeted review of systems.
O - Objective Vital signs, general appearance, focused physical examination, and available diagnostic results. Record only
what was observed or measured.
A - Assessment Primary diagnosis plus prioritized differential diagnoses. Link each conclusion to supporting and opposing
evidence.
P - Plan Diagnostics, medication and nonmedication management, education, preventive care, referrals, follow-up, and
specific return precautions.
HPI ORGANIZATION
Element Questions to ask
Onset / Context When did it begin? What was happening at the time?
Location / Radiation Where is it? Does it spread?
Duration / Timing Constant or intermittent? Pattern? Progression?
Character / Severity How does it feel? Severity and functional effect?
Aggravating / Relieving What worsens or improves it? Treatments tried?
Associated symptoms What important positives and negatives help separate the differential diagnoses?
DOCUMENTATION QUALITY CHECK
Check Question
Consistency Do the assessment and plan match the history, vital signs, and exam?
Specificity Are diagnoses and return precautions clear rather than vague?
Safety Were urgent alternatives, contraindications, pregnancy status, and medication risks considered?
Follow-up Is timing defined and linked to the condition or treatment change?
Student revision resource - not official course material Page 3
