1.Choose a client from your clinical setting or an imaginary case
2.Write a SOAP note based on your client. No area of assessment is to be deleted or abbreviated.
3.There is to be a minimum of two clinical research references that will be related to your case’s history of presenting problem, assessment/care of the patient, and plan of action/treatment.
4.GOOGLE or WIKIPEDIA not allowed
5.SOAP notes should be a thorough focused note pertaining to the presenting problem and the area of specialty that you are assigned.
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SUBJECTIVE (35 POINTS) |
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1-Identified and collected the necessary data 2-Categorized and organized data using the appropriate format 3-Incorporated all pertinent data/facts 4- Used proper documentation |
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OBJECTIVE (35 POINTS) |
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1-Identified and collected the necessary data 2-Categorized and organized data using the appropriate format 3-Incorporated all pertinent data/facts 4-Age appropriate developmental documentation 5- Used proper documentation |
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ASSESSMENT (15 POINTS) |
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1-Filtered relevant data from irrelevant data 2-Interpreted relationships/patterns among data (e.g., noted trends) 3- State differential Diagnosis 4-Integrated information to arrive at diagnosis 5-Identified risk factors 6- Used proper documentation |
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PLAN (15 POINTS) |
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1-Recommended an appropriate plan for each problem 2-Included recommendations for non-drug and drug therapy 3-Included recommendations for monitoring 4- Included health education 5- Included follow-up& referrals if indicated |
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