Week 8 Assignment 1: Comprehensive SOAP Note
Assignment 1: Comprehensive SOAP Note
PRAC 6568: Synthesis in Advanced Nursing Practice of Patients in Family Care Settings Practicum
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.
- Review the Comprehensive SOAP Note Template.
- Select a patient who you saw at your practicum site during the last 5 weeks. With this patient in mind, consider the following:
- Subjective: What details did the patient provide regarding the 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 CPT and ICD-10 codes 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 â€œahaâ€ moment? What would you do differently in a similar patient evaluation?
By Day 7
Submit your Comprehensive SOAP Note. You must submit two files for the SOAP note, including a Word document and scanned pdf/images of each page that is initialed and signed by your preceptor.