Select a patient that you examined during the last three weeks. With this patient in mind, address the following in a SOAP Note:
•Subjective: What details did the patient provide regarding her personal and medical history?
•Objective: What observations did you make during the physical assessment?
•Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
•Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
•Reflection notes: What would you do differently in a similar patient evaluation?
SOAP Note Evaluation Criteria
Each SOAP Note is worth 100 points. The original grading criteria has been modified to make it clear how points would be allocated. The point allocation for each major category was not altered.
SOAP Notes should reflect new experiences related to your practicum experiences in this course. Your submissions should be your original work and cannot be repurposed from previous courses.
Your SOAP Note should be based on an individual patient and address the following:
• Subjective: Details the patient provided regarding his or her personal and medical history (15 points)
• How points will be allocated
• CC (1 point)
• Pertinent positives (OLDCARTS) (5 points)
• Pertinent negatives (from ROS) (5 points)
• Pertinent PMH, SH, and FH (3 points)
• Medications and drug/food allergies are not included (1 point)
• Objective: Observations that you make during the physical assessment (15 points)
• How points will be allocated
• VS including BMI (2 points)
• Heart and lungs (1 point)
• Systems or specialty exam techniques that are not necessary to arrive at a diagnosis are included. (-1 for each up to 5 points)
• Systems or specialty exam techniques that are necessary to arrive at your diagnosis are omitted. (-1 for each up to 5 points)
• Diagnostic test results (2 point)s
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