Description
For this assignment, students will create a SOAP note reflective of the patient care experience in the clinical setting under the supervision of the clinical preceptor in the role of the clinical provider. This assignment will evaluate the student clinical reasoning skills, interviewing skills, physical exam skills, selection of diagnostic testing, differential diagnosis, pharmaceutical and non-pharmaceutical treatment, patient education, and follow-up plan.
Students must develop the clinical skills and knowledge required for safe practice and deliver best patient outcomes upon graduation. SOAP notes should be used to document each patient seen in the clinical setting. Clear, concise, and thorough documentation is required for continuity of care, safe practice, appropriate reimbursement, and prudent risk management.
When developing the SOAP note, students should use the assignment criteria below and the ACON SOAP Note Template found in this weeks’ module. Students should include complete subjective and objective information to support the assessment and plan. The plan must include diagnostic and treatment measures, patient education, and follow-up.
Keep the following points in mind:
Use the ACON SOAP Note template as a guide
Identify and collect relevant subjective and objective data
Use proper medical terminology and documentation
Use proper ICD-10 coding and Current Procedural Terminology (CPT) E/M coding
Identify any cultural/religious/racial/gender influences on care
Assignment Criteria:
Students will complete a SOAP note and include the following:
Subjective findings
Chief complaint (CC)
History of present illness (HPI)
Use mnemonic: onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, and severity (OLDCARTS)
Past medical/surgical/social/family history
Medications
Allergies, prescription/over the counter (OTC)/herbal medications
Comprehensive review of systems (ROS)
Objective findings
Appropriate physical examination based on subjective findings
Relevant positive and negative diagnostic testing including previous pertinent diagnostic tests related to visit
Screening tools and positive and negative results
Assessment
Correct primary diagnosis
Correct differential diagnoses
Correct ICD-10/Current Procedural Terminology (CPT) codes
Plan
Identify and orders correct diagnostics, prescriptions, referrals, and follow-up plan
Patient education relative to treatment plan.
Correctly written out a prescription for one medication prescribed for the patient.
If a medication not prescribed, write out a prescription for a medication that might be prescribed for a similar patient
Include two current evidence-based guidelines and/or peer-reviewed scholarly journals to support patient education and treatment plan. The student can pick one evidence-based guideline and one scholarly article. References should be from scholarly peer-reviewed journals (check Ulrich’s Periodical Directory) and be less than five (5) years old.
APA format required (attention to spelling/grammar, a title page, a reference page, and in-text citations). Submit by the posted due date.
