Practicum Experience: SOAP Note Assignment

Practicum Experience: SOAP Note and Time Log Assignment

Practicum Experience: SOAP Note and Time Log Assignment

Practicum Experience: SOAP Note Assignment

In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum Experiences and connect these experiences to your classroom experience. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Please refer to the Seidel, et. al. book excerpt and the Gagan article located in this week’s Learning Resources for guidance on writing SOAP Notes. Practicum Experience: SOAP Note and Time Log Assignment

After completing this week’s Practicum Experience SOAP, 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?

SOAP NOTE TEMPLATE

Select a patient that you have examined in the clinical setting to complete a SOAP Note.You will include evidence-based practice guidelines in the management plan, and include rationales for differential diagnoses (cite source).  Please include a heart exam and lung exam on all clients regardless of the reason for seeking care.  So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam.  The pertinent positive and negative findings should be relevant to the chief complaint and health history data.  This template is a great example of information documented in a real chart in clinical practice. The term “Rule Out…” cannot be used as a diagnosis. Please describe appearance of area assessed and refrain from using the term “normal” when documenting this note. Practicum Experience: SOAP Note and Time Log Assignment

  1. Subjective Data
    • Chief Complain (CC): A single statement in patient’s own words with quotations that include timing.  Example:  “ My head has been hurting for 2 days”
    • History of Present Illness (HPI): Use OLDCARTS pneumonic to document this data.  Please see sample HPI in Docsharing
    • Last Menstrual Period (LMP- if applicable)
    • Allergies:
    • Past Medical History:
    • Family History:
    • Surgery History:
    • Social History (alcohol, drug or tobacco use):
    • Current medications:
    • Review of Systems (Remember to inquire about body systems relevant to the chief complaint & HPI.  Please do not include exam findings in this section; only document patient or caregiver’s answer to your history questions)
  2. Objective Data
    • Please remember to include an assessment of all relevant systems based on the CC and HPI.  The following systems are required in all SOAP notes.  You will proceed to assess additional pertinent systems. Practicum Experience: SOAP Note and Time Log Assignment
      • Vital Signs/ Height/Weight:
      • General Appearance:
      • HEART:
      • RESP:
      •  Assessment
      • Differential Diagnosis (include rationales and cite source)
      • 3.Medical Diagnosis
      • PLAN
        • Prescriptions with dosage, route, duration, and amount prescribed and if refills provided
        • Diagnostic testing
        • Health Education/Promotion/Maintenance Needs
        • Referrals
  • Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit; Example —F/U in 2 weeks; Plan to repeat CXRAY on RTC (return to clinic)
  • Reflection:  What was your “aha” moment? What would you do differently in a similar patient evaluation?
  • References:  Please include at least 3 evidence-based sources in APA format.

ADDITIONAL INSTRUCTIONS FOR THE CLASS –

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SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS – Practicum Experience: SOAP Note and Time Log Assignment

We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.

  • Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

  • Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week. Practicum Experience: SOAP Note and Time Log Assignment

  • APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition. Practicum Experience: SOAP Note and Time Log Assignment

  • Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

  • LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score. Practicum Experience: SOAP Note and Time Log Assignment

  • Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

  • Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

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We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium. Practicum Experience: SOAP Note and Time Log Assignment

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