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:
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 Note||Rationale||This 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|
|CC: Vaginal discharge with itching||Diff. 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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