SOAP Note 1
Patient is a 67 year female
History of Appendicitis surgery
Married to a male
2 sons
No allergies
Pretty healthy weight
Takes daily vitamins
Only medication is blood pressure med, has been taking it for a couple years now
Chief complain is came in because she was having a lot of lower back pain
A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.
Instructions:
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
|
S = |
Subjective data: Patient’s Chief Complaint (CC). |
|
O = |
Objective data: Including client behavior, physical assessment, vital signs, and meds. |
|
A = |
Assessment: Diagnosis of the patient’s condition. Include differential diagnosis. |
|
P = |
Plan: Treatment, diagnostic testing, and follow up |
Click here to access and download the SOAP Note Template
Download Click here to access and download the SOAP Note Template
Submission Instructions:
· Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.
· You must use the template provided. Turnitin will recognize the template and not score against it.
· Complete and submit the assignment using the appropriate template in MS Word by 11:59 PM ET on Sunday.
· Late work policies, expectations regarding proper citations, acceptable means of responding to peer feedback, and other expectations are at the discretion of the instructor.
· You can expect feedback from the instructor within 48 to 72 hours from the Sunday due date.
