Topic – Episodic SOAP Note and Reflection: Craig Harris
Assignment Content
This week, you learned about the male genitourinary system and how to collect a proper history. It is time to practice your documentation skills. In this assignment, you write an episodic SOAP note for Craig Harris and reflect on potential barriers to care and evidence-based practices related to the diagnoses. Complete Parts 1 and 2 below.
Part 1: SOAP Note
Read the Craig Harris Scenario.
To document your SOAP note for Craig Harris:
Use this SOAP Note Template:
SOAP Note Template.docx
And this SOAP Note Structure Guide:
SOAP Note Stucture Guide.docx
Your SOAP Note must include complete documentation. For missing information, such as DOB, O2 sats, family history, employment history, etc. please make up this information and add to your note.
The assessment and plan sections will not be graded but should be completed to ensure documentation of a complete SOAP note. You will also use this information to complete your E&M coding for the visit.
Make sure to:
Document all relevant information using appropriate terminology.
List the appropriate ICD-10 codes and E&M codes for the diagnoses.
Part 2: Reflection
Now that you have completed your SOAP note for Craig Harris, it is time for reflection. This reflection is your opportunity to review what you learned about the patient, the process, and the outcomes in preparation for future patient encounters. The reflection must include a discussion about an evidence-based practice to improve the quality of care the patient receives.
Write a 700-word reflection providing a rationale for your completed SOAP note with consideration for the interview information provided in the patient scenario. DO NOT EXCEED 800 WORDS.
Address the following in your reflection:
Locate and review at least 1 current evidence-based article that discusses evidence-based guidelines or new research relating to each diagnosis. EVIDENCE BASED RESOURCES ARE < 5 YEARS OLD. Provide a brief summary of the article(s).
Identify a minimum of 2 barriers to quality health care the patient can potentially experience per the information provided in the interview (e.g., cultural, linguistic, economic, previous conditions).
Explain how you, as the nurse practitioner, can address these barriers to improve the quality of care the patient receives.
Reference a minimum of 2 peer-reviewed articles to support your reflection.
SEE THE UPLOAD TO BE USE FOR THE ASSIGNMENTS
Bickley, L. S. (2020). <i>Bates’ guide to physical examination and history taking</i> (13th ed.). Wolters Kluwer Health. Ch 20 & 22 .
Format your citations according to APA guidelines.
Submit your SOAP note and reflection.
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