SOAP Analysis

Guidelines:

1-Choose a client from your clinical setting & write up a case analysis (see below for content).

2- SOAP note from your clinical should be included (remove all patient identifiers)

5- Each SOAP is 10% of your total grade;  attach grading rubric to each paper submitted

*** CASE HAS TO BE ON PATIENT THAT IS 63 YEARS OLD FEMALE THAT HAS LEFT KNEE PAIN CONNSISTENT WITH ARTHRITIS, XRAYS WERE DONE, PT WAS SENT HOME WITH INDOMETHACIN, NOT ABLE TO TAKE PREDNISONE BECAUSE OF TYPE 2 DIABETES MELLITUS. REFERRAL PLACE FOR RHEUMATOLOGY AND PCP. PT IS OF HISPANIC CULTURE, NON-INSURED, UNABLE TO PAY FOR HEALTHCARE (PLEASE INCLUDE AND EXPAND ON ALL OF THIS IN SOAP ANALYSIS). 

SUBJECTIVE Analysis (10 POINTS)

Score received

1- Compare & contrast subjective section with literature taking into consideration the following criteria; 

  a-Identified and collected the necessary data including the  patients culture

  b-Categorized and organized data using the appropriate format

  c-Incorporated all pertinent data/facts

 d- Used proper documentation

OBJECTIVE Analysis (10 POINTS)

Score received

1- Compare & contrast objective section with literature taking into consideration the following criteria

   a. Identified and collected the necessary data

   b. Categorized and organized data using the appropriate format 

c.Incorporated all pertinent data/facts

   d. Used proper documentation

ASSESSMENTAnalysis (35POINTS)

Score received

1- Compare & contrast subjective section with literature taking into consideration the following criteria

   a-Filtered relevant data from irrelevant data

   b.-Interpreted relationships/patterns among data

(e.g., noted trends)

c.Integrated information to arrive at diagnosis

d.Identified risk factors

    e.  Differentials listed & discussed in comparison to actual diagnosis

    e. Used proper documentation

PLAN Analysis (35 POINTS)

Score received

1- Compare & contrast subjective section with literature taking into consideration the following criteria

    a. Recommended an appropriate plan for each problem

    b-Included recommendations for non-drug and drug therapy

     c-Included recommendations for monitoring

   d- Included health education

    e- Included follow-up& referrals