SOAP Note with Rationale Assignment

Guidelines for Completion

Choose a SOAP note from an encounter in your clinical setting.  It should be from a focused encounter.It should not be from a follow up or medication refill only.  Remove all patient unique identifiers (medical record numbers, social security numbers, addresses, etc.).  Convert the note so that it fits in the table format used for the example below (actual SOAP goes in the left column).

In the right column:

  • For each part of the history and physical exam give a brief explanation of what you were thinking (critical thinking and diagnostic reasoning) as you interviewed and examined the patient. These explanations do not need to be complete sentences.
  • Provide rationale for why you included specific patient responses to questions, physical findings and laboratory results in your encounter and note.
  • For each of the above, explain why it is important or significant (helping to rule in or rule out possible differentials). 
  • Your rationales should be supported by the literature (journal articles, information from your texts, guidelines). Corresponding citations (where appropriate) should appear in the right-hand column. The full reference for the citation should appear in a reference list at the end of the assignment. You may use your textbook as areference

References:

Use at least 3 references for this assignment.  Acceptable references include textbooks, journal articles, clinical practice guidelines, and clinical decision-making tools, such as Dynamed.  At least one reference should be from a journal article obtained through a database search (e.g. MedLine, CINHAL, SCOPUS).  The full reference information should appear after the table.  Use APA format for all references and citations.

SOAP NoteRationaleThis column is not included in your assignment.  It is included here to help explain what should be included in the Rationale column.
Biographical Info: KT, Anytown, KS
Age 23, Cauc, F
Insurance: Health Plan USA
Source: self & reliable
Demographics are important psychosocially. Some diagnoses are more common in particular age groups, races, or sexes (Gorroll & Mulley, 2014) Knowing whether or not a patient has insurance may affect choice of medication and other treatments 
SUBJECTIVE:  
CC: Vaginal discharge with itchingDiff. Dx: bacterial vaginosis, STI, PID, UTI, yeast infection (Gorroll & Mulley 2014).                                    A patient comes to you with presenting symptoms.  When you hear the CC or the presenting symptoms you are already thinking about what it could possibly be (or the differential diagnoses).  In this column, for your rationale, write what you were thinking (the differentials) when the patient presented with his/her symptoms. 
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