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.
To prepare:
- Review the attached Focused SOAP Note Template.
- Select a patient who you saw at your practicum site during the last 3 weeks. (Note to writer: See attached subject pt. details) 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?
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