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 Utilize the information below that is copied-and-pasted out of the SOAP Note Assignment instructions to assist you in formatting your post:Assessment (A):Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.

 Utilize the information below that is copied-and-pasted out of the SOAP Note Assignment instructions to assist you in formatting your post:Assessment (A):Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.

 

Utilize the information below that is copied-and-pasted out of the SOAP Note Assignment instructions to assist you in formatting your post:

Assessment (A):

Diagnosis/Diagnoses: Start with the presenting chief complaint diagnosis first. Number each diagnosis.

A statement of current condition and all other chronic illnesses that were addressed during the visit must be included (i.e. HTN-well managed on medication}.

Remember the data you provide in the ‘S’ data set and the ‘O’ data set must support this diagnosis (or these diagnoses if more than one is listed}. Pertinent positives and negatives must be found in the write-up.

Plan (P):

These are the interventions that relate to each individual, numbered diagnosis.

Document individual plans directly after each corresponding assessment (Ex. Assessment­ Plan). Address the following aspects (they should be separated out as listed below):

Diagnostics: labs, diagnostics testing – tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint

Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications.

Educational: information clients need in order to address their health problems. Include follow­ up care. Anticipatory guidance and counseling.

Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.

NOTE: please input N/A where appropriate for the above 4 categories, do not assume that your clinical faculty person will know it was not applicable.

Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.


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