SOAP NOTE 1
This focused SOAP note assignment is a way to reflect on your Practicum experiences and connect them to your classroom experience. Focused SOAP notes are often used in clinical settings to document patient care. They provide a standard, systematic format for collecting patient information. Similar to learning to compute math problems by hand before you move to a calculator, you are required to use a Word document template in this course and document everything manually. In your career, however, you are likely to encounter electronic health record systems with SOAP documentation capabilities such as search functions and symptom drag and drops that will streamline the process.
To prepare:
- Review this weeks Learning Resources, including the Focused SOAP Note Template.
- Select a patient who you saw at your practicum site during the last 3 weeks. With this patient in mind, consider the following:
- Subjective: What details did the patient provide regarding his or her personal and medical history?
- Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
- Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
- Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
- Reflection notes: What was your aha moment? What would you do differently in a similar patient evaluation?
THIS IS THE CASE OF THE PATIENT
Date I saw the patient is 3/11//26
Patient Number: 039
A 62-year-old female presented with complaints of intermittent swelling in both ankles over the past two weeks, worse at the end of the day. Past medical history included hypertension and obesity. Vital signs were BP 138/84 mmHg, HR 76 bpm, RR 16/min, Temp 98.2 F, SpO2 97% on room air, BMI 32. Cardiovascular and respiratory examination were unremarkable except for mild bilateral ankle edema. Diagnosis is Peripheral edema – ICD-10: R60.0. Labs ordered included CMP, BNP, urinalysis, and TSH to evaluate possible causes of edema. The patient was prescribed Hydrochlorothiazide 25 mg orally once daily and advised to reduce sodium intake and elevate legs when resting. Follow-up scheduled in four weeks.
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