Create one SOAP note reflective of the patient care experience in the clinical setting under the supervision of the clinical preceptor in the role of the clinical provider.
ACON SOAP Note (one at 5 points)
For this assignment, students will create one SOAP note reflective of the patient care experience in the clinical setting under the supervision of the clinical preceptor in the role of the clinical provider. This assignment will evaluate student clinical reasoning skills, interviewing skills, physical exam skills, selection of diagnostic testing, differential diagnosis, pharmaceutical and non-pharmaceutical treatment, patient education, and follow-up plan.
Students must develop the clinical skills and knowledge required for safe practice and deliver best patient outcomes upon graduation. SOAP notes should be used to document each patient seen in the clinical setting. Clear, concise, and thorough documentation is required for continuity of care, safe practice, appropriate reimbursement, and prudent risk management.
When developing the SOAP note, students should use the assignment criteria below and the ACON SOAP Note Template found in Module Week 2. Students should include complete subjective and objective information to support the assessment and plan. The plan must include diagnostic and treatment measures, patient education, and follow-up.
Keep the following points in mind:
Use the ACON SOAP Note template as a guide
Identify and collect relevant subjective and objective data
Use proper medical terminology and documentation
Use proper ICD-10 coding and Current Procedural Terminology (CPT) E/M coding
Identify any cultural/religious/racial/gender influences on care
Assignment Criteria:
Students will complete a SOAP note and include the following:
Subjective findings
Chief complaint (CC)
History of present illness (HPI)
Use mnemonic: onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, and severity (OLDCARTS)
Past medical/surgical/social/family history
Medications
Allergies, prescription/over the counter (OTC)/herbal medications
Review of systems (ROS)
2. Objective findings
Appropriate physical examination based on subjective findings
Relevant positive and negative diagnostic testing including previous pertinent diagnostic tests related to visit
Screening tools and positive and negative results
3. Assessment
Correct primary diagnosis
Correct differential diagnoses
Correct ICD-10/Current Procedural Terminology (CPT) codes
4. Plan
Identify and order correct diagnostics, prescriptions, referrals, and follow-up plan
Patient education relative to treatment plan.
Correctly written out a prescription for one medication prescribed for the patient.
If a medication not prescribed, write out a prescription for a medication that might be prescribed for a similar patient
5. Include two current evidence-based guidelines and/or peer-reviewed scholarly journals to support patient education and treatment plan. References should be from scholarly peer-reviewed journals (check Ulrich’s Periodical Directory) and be less than five (5) years old.
APA format required (attention to spelling/grammar, a title page, a reference page, and in-text citations). Schuiling & Likis: Chapters 25, 26, 27, 28, and 30Week 5 Content
Go to Modules on the Course Menu, click, and scroll down to Week 5
content
Journal Article:
The North American Menopause Society. (2022). The 2022 hormone therapy
position statement of the North American Menopause Society.
Menopause, 20(7), 767-794.
Class Lecture/Discussion
In-class activities will be facilitated by the instructor and may include small
groups, shared pairs, individual work, groups discussions, and individual/group
presentations. Prior to class, read the weekly content and be prepared to discuss
the following:
Gynecologic infections
Sexually transmitted infections
Urinary tract infection
Urinary incontinence
Menstrual cycle
Uterine bleeding
Benign gynecological conditions
Menopause
Pelvic pain
Hyper-androgenic disorders
Requirements: Varies
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