Practicum: SOAP Note

With this patient in mind in OB/GYN clinic, address the following in a SOAP Note:(topic choice: abnormal uterine bleeding or any other topic)

Subjective: What details did the patient provide regarding or her personal and medical history?

Objective: What observations did you make during the physical assessment?

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. 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, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.

Reflection notes: What would you do differently in a similar patient evaluation?