What details did the patient provide regarding his or her personal and medical history?After completing this week’s Practicum Experience, select a patient that you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:

After completing this week’s Practicum Experience, select a patient that you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:

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?

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?
Reflection notes: What would you do differently in a similar patient evaluation?
Please refer to the Learning Resources in Week 3 for guidance on writing SOAP Notes.
** Write SOAP on adult patient.
Gagan, M. J. (2009). The SOAP format enhances communication. Nursing New Zealand, 15(5),15


 

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