Again the course in NUR507 children and family but this clinical is pediatrics for children and adolescents meaning that the soap not MUST be on a child.
A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.
Instructions:
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
| S = | Subjective data: Patients Chief Complaint (CC). |
| O = | Objective data: Including client behavior, physical assessment, vital signs, and meds. |
| A = | Assessment: Diagnosis of the patient’s condition. Include differential diagnosis. |
| P = | Plan: Treatment, diagnostic testing, and follow up |
Submission Instructions:
- Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.
Your first SOAP note assignment is due this week. I cannot stress the importance of reading and following the rubric accordingly. Please note that these assignments carry a heavy weight on your grade and there will be NO RESUBMISSIONS after due date. If you have any questions, please reach out ahead of time.
Keep in mind that the clinical course is a required component of NUR507. If you fail 1 component, both will be considered failures altogether.
Tips for SOAP note assignments:
- Do NOT choose a patient who came for a follow-up/wellness visit/annual check-up visit.You must select 3 patients out of the 125 that you must see throughout the term. Select a patient that has medical conditions that allow you to properly develop your note. If you cannot develop a required section of the SOAP note because you chose a patient who came for a follow-up/wellness/annual check-up visit, then you will not get points for that section. Do not use a template that you already used and submitted on previous courses. Start adding the information on a new template.
- Read the rubric and address it accordingly. Do not have an empty section in the template.
- Do NOT document normal or WNL as an assessment finding
- Review the difference between ROS & physical examination (remember that in your ROS you only document subjective data and in the physical exam you only document objective data)
- Turn-it-in score must be 20% or less (more than 20% will result in a “0”). AI report will be run for all SOAP notes.
- Do NOT alter the template – do not remove or add sections
- Look at the LAB(S) component of the rubric and find where to document that on the template (at the end of the physical examination)
- Follow the rubric
- ASK when in doubt (ahead of time)
Please do not take this information lightly. Your SOAP note scores will impact your grade in the clinical course drastically. You have all the tools and resources needed to be successful. Be proactive.
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