Practicum Experience: SOAP Note and Time Log

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.
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.

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.
     • 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.

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