Week 2 SOAP NOTE

Week 2 SOAP NOTE

Create a SOAP NOTE using the guidelines and template provided below.

Topic: Menorrhagia on a 18 y/o female patient.

CC: I have been having heavy periods for the past 3 months lasting 10 to 11 days with constant pain in the pelvis area.

Guidelines:

Subjective Information: “CC”, HPI :OPQRST IF f/u: health status since the last visit, response to therapies. PMH, PSH, FH, ROS complete.

Objective Information: Complete physical exam with critical elements related to subjective data.

Assessment: Minimum of 3 differentials supported by S + O data Final diagnosis noted, and optimal and thorough subjective and objective assessment is presented for final diagnosis.

Plan: Diagnostic tests/therapies/follow-up, Patient education, health promotion. Medications listed with dosage/SE/Education/

Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence-based reasoning & literature in designing the plan of care, compare to the plan of care implemented.

SOAP NOTE

Name: Date: Time:
  Age: 18 years Sex: Female
SUBJECTIVE

CC:  I have been having heavy periods for the past 3 month lasting 10 to 11 days with constant pain in the pelvis area.

 

HPI:  (Use OLD CARTS tool)

 

Medications:

 

PMH:

Allergies: 

Medication Intolerances:

Immunizations:

Chronic Illnesses/Major traumas:

Hospitalizations/Surgeries (include delivery of pregnancies here)

 

Family History

 

Social History

 

ROS

General

 

Cardiovascular

 

Skin

 

Respiratory

 

Eyes

 

Gastrointestinal

 

Ears

 

Genitourinary/Gynecological

 

Nose/Mouth/Throat

 

Musculoskeletal

 

Breast

 

Neurological

 

Heme/Lymph/Endo

 

Psychiatric

 

OBJECTIVE
Weight: BMI: Temp: BP:
Height: Pulse: Resp:

General Appearance

 

Skin

 

 

HEENT

 

 

Cardiovascular

 

Respiratory

 

Gastrointestinal

 

Breast

 

Genitourinary

 

Musculoskeletal

 

Neurological

 

Psychiatric

 

Lab Tests (list the results if you have them)

 

Special Tests (done or ordered during the OV)

No special tests ordered.

 

 

 Diagnosis – include the appropriate ICD – 10 Code for each diagnosis used

Primary Diagnosis

Differential Diagnoses (these must be different from the Primary Diagnosis)

 

Plan/Therapeutics (explain fully)

 

 

 Evaluation of patient encounter

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ADDITIONAL INSTRUCTIONS FOR THE CLASS

Who We Are 

We are a professional custom writing website. If you have searched for a question and bumped into our website just know you are in the right place to get help with your coursework.

Do you handle any type of coursework?

Yes. We have posted our previous orders to display our experience. Since we have done this question before, we can also do it for you. To make sure we do it perfectly, please fill out our Order Form. Filling the order form correctly will assist our team in referencing, specifications, and future communication.

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  • 2. Fill in your paper’s requirements in the “PAPER INFORMATION” section and the system will calculate your order price/cost.
  • 3. Fill in your paper’s academic level, deadline, and the required number of pages from the drop-down menus.
  • 4. Click “FINAL STEP” to enter your registration details and get an account with us for record-keeping and then, click on “PROCEED TO CHECKOUT” at the bottom of the page.
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  • Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

  • Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

  • APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

  • Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

  • LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

  • Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

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Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

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