ASOAPnoteisamethodofdocumentationemployedbyhealthcareproviderstorecordandcommunicatepatientinformationinaclear.docx
A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.
Instructions:
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
S =
Subjective data: Patient’s Chief Complaint (CC).
O =
Objective data: Including client behavior, physical assessment, vital signs, and meds.
A =
Assessment: Diagnosis of the patient’s condition. Include differential diagnosis.
P =
Plan: Treatment, diagnostic testing, and follow up
Submission Instructions:
· Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.
· You must use the template provided. Turnitin will recognize the template and not score against it.
· Your submission will be reviewed for plagiarism through Turnitin.
· Complete and submit the assignment using the appropriate template in MS Word by 11:59 PM ET on Sunday.
SOAPNoteTemplate.docx
SOAP NOTE TEMPLATE
Review the Rubric for more Guidance
Demographics
Chief Complaint (Reason for seeking health care)
History of Present Illness (HPI)
Allergies
Review of Systems (ROS)
General:
HEENT:
Neck:
Lungs:
Cardio
Breast:
GI:
M/F genital:
GU:
Neuro
Musculo:
Activity:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
Vital Signs
Labs
Medications
Past Medical History
Past Surgical History
Family History
Social History
Health Maintenance/ Screenings
Physical Examination
General:
HEENT:
Neck:
Lungs:
Cardio
Breast:
GI:
M/F genital:
GU:
Neuro
Musculo:
Activity:
Psychosocial:
Derm:
Diagnosis
Differential Diagnosis
ICD 10 Coding
Pharmacologic treatment plan
Diagnostic/Lab Testing
Education
Anticipatory Guidance
Follow up plan
Prescription
See Below (scroll down)
References
Grammar
EA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)______________________________ Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________ Refill: _________________
No Substitution
Signature:____________________________________________________________
Signature (with appropriate credentials):_____________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
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