nurs 6531 soapnote 1

Assignment: Practicum Experience – SOAP Note and Journal

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?