24 Jan C.M. is an 89-year-old woman who presents with her daughter to the provider’s office
Using resources approved by the instructor, students will complete a problem focused SOAP note on assigned patient/body system. The note must be completed and turned in using a Word document and will be evaluated in Turnitin.com for originality. Though the SOAP note itself does not need to be in APA format, the assignment should be formatted with title & reference pages.
SOAP note Assignment
Follow the directions per the syllabus!
Include a title page and reference page.
It should be formatted as below:
Title Page
SOAP note with sections Subjective,Objective, Assessment, Plan
Reference Page
***If there are things that you would have asked or wanted to observe for the subjective and objective portion – List them at the end of the sections they would go under and mark them with an * – this gives me insight in to your critical thinking and desire to know more……There is enough data given below to complete a SOAP note on this patient.
Scenario:
C.M. is an 89-year-old woman who presents with her daughter to the provider’s office. The daughter is concerned because her mother has not been eating well. The patient does not drive and lives alone. Medications: metoprolol 12.5 mg per day, Synthroid 0.75 mg per day. Patient cooks light meals and a 24-hour diet recall reveals approximately 1100-calorie intake. The daughter shops for the patient. Her vitals signs are T 37 P 72 R 12 BP 104/64. Height: 5 feet, 1 inch. Weight: 105 lb. Weight last visit, 3 months ago: 115 lb. PMH: HTN, Hypothyroid. Oral mucosa dry, gums bleeding, dentures loose. Poor skin turgor.
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