Week 6 – Focus SOAP Note – Gastrointestinal
Prepare a focused assessment SOAP note for a gastrointestinal condition. List a minimum of three differential diagnosis. The primary diagnosis must be at the top of the list. I will include the SOAP template and my previous SOAP note that was already revised by my instructor, which have errors I have to correct. Also, check the Rubric for grading criteria.
Prepare and complete an Episodic/Focus Note Template Form where you will gather patient information and relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors such as age, ethnic group, past medical history (PMH), socioeconomic status, and cultural background. For this Assignment, you will work with a patient with a gastrointestinal condition. All Physical Exams (PE’s) in this course are focused, so you only need to examine the area of chief complaint and any pertinent history system (hx of GIB, IBS… examine the abdomen, history of DM – look at skin), and always, always, always do a cardiac and respiratory exam.
All assignments are considered formal in this course and require APA 7.
Assignment:
- 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?
