Superior Essay Writers | Subjective, objective, assessment, and plan Note

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Superior Essay Writers | Subjective, objective, assessment, and plan Note

The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by health care providers to write out notes in a patient’s chart, along with other common formats, such as the admission note.

  1. Select a “patient” (friend or family member) on whom to perform a complete H&P.
  2. NOTE: DO NOT USE REAL NAMES OR INITIALS OR OTHERWISE IDENTIFY YOUR “PATIENT.” FAILURE TO MAINTAIN PRIVACY WILL RESULT IN A FAILING SCORE.
  3. Using the format specified below, write a 1 to 2 page SOAP note on your “patient.” The HPI should be presented in a paragraph, and the rest of the data including the ROS should be presented in a list format.
  4. Collect only the information that is pertinent to the chief complaint of the patient to include in your SOAP note. Aim for a single page using normal margins and format.
  5. The SOAP Note must contain all required elements as outlined in the rubric below.
  6. You must self-score your SOAP note using the rubric and attach it to the assignment.

Subjective Data
• Biographic Data:– Age/race/gender, date, occupation, language/communication needs.
• Source – and reliability
• Chief Complaint (reason for seeking care)- make every attempt to use patient’s own words.
• History of Present Illness (HPI)- complete, clear, chronological account of events prompting patient to seek care. Use OLDCARTS or PQRST to gather data but do not include acronym in HPI. Document in paragraph format.
• Past Medical History (PMH)- childhood, adult illnesses, serious illnesses/hospitalizations, obstetric hx, Immunizations, last exam
• Allergies, medication, food, environmental
• Medications- Rx, OTC, herbal, etc.
• Family History- write a genogram diagram or outline; age, health, age, and cause of death of each family member going back three generations.
• Personal and Social History- interests, support systems, occupation, highest level of education, job history, financial situation, spiritual beliefs, lifestyle, alternative health care practices, sexual and obstetric history.
• Review of Systems (ROS)- series of questions from head to toe. Must be in the following order – include health promotion practices:
• General Survey
• Integumentary
• Head, Eyes, Ears, Nose, and Throat
• Neck/thyroid
• Breasts and axillary lymph nodes
• Respiratory
• Cardiovascular
• Peripheral vascular
• Gastrointestinal
• Genitourinary
• Genital/Reproductive system
• Sexual health
• Musculoskeletal
• Neurological (must include reflexes on PE)
• Hematologic
• Endocrine
• Functional assessment – include activities of daily living
• Self-esteem/self-concept
• Activity/exercise
• Sleep/rest/nutrition, include
• Nutritional status assessment- identify if patient is at risk for malnutrition or over nutrition
• Interpersonal relationships
• Spiritual resources
• Coping and stress management
• Personal habits – alcohol, tobacco, street drugs
• Environment/Hazards
• Intimate partner violence
• Occupational health
• Perception of health
• Developmental Competence – children, pregnant women, older adult
Objective data
• Physical Examination (PE)
• General Survey
• Integumentary
• Head, Eyes, Ears, Nose, and Throat
• Neck/thyroid
• Breasts and axillary lymph nodes
• Respiratory
• Cardiovascular
• Peripheral vascular
• Gastrointestinal
• Genitourinary
• Genital/Reproductive system
• Sexual health
• Musculoskeletal
• Neurological (must include reflexes on PE)
• Hematologic
• Endocrine
Assessment
• Diagnosis with rationale
• Differential diagnosis with rationales
Plan
• Dx plan – include diagnostic tests needed (lab, x-ray, etc.)
• Tx plan – include recommended treatment – cite national guidelines
• Patient education – including specific medication teaching
• Referral/Follow up
• Health Maintenance – include health promotion recommendations from AHRQ (ePSS app) according to age/gender/conditions

Sample Solution

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