16 Dec Developing a Focused SOAP Note

This focused SOAP note assignment is a way to reflect on your Practicum experiences and connect them to your classroom experience. Focused SOAP notes are often used in clinical settings to document patient care. They provide a standard, systematic format for collecting patient information. Similar to learning to compute math problems by hand before you move to a calculator, you are required to use a Word document template in this course and document everything manually. In your career, however, you are likely to encounter electronic health record systems with SOAP documentation capabilities such as search functions and symptom drag and drops that will streamline the process.

All SOAP notes must be signed and each page must be initialed by your preceptor. When you submit your SOAP Note, you should include the complete SOAP Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your SOAP Note using Turnitin.

Please Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.

Resources

Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources.

WEEKLY RESOURCES

To prepare:

· Review this week’s Learning Resources, including the Focused SOAP Note Template.

· Select a patient who you saw at your practicum site during the last 3 weeks. With this patient in mind, consider the following:

· Subjective: What details did the patient provide regarding his or her personal and medical history?

· Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.

· Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. 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? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.

· Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

By Day 7

Submit your Assignment. You must submit two files for the SOAP note, including a Word document and scanned pdf/images of each page that is initialed and signed by your preceptor.

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

1. To submit your completed assignment, save your Assignment as WK4Assgn1+last name+first initial.

2. Then, click on Start Assignment near the top of the page.

3. Next, click on Upload File and select Submit Assignment for review.

4. Rubric

PRAC_6568_Week4_Assignment1_Rubric