SOAP note

This Week's Topics

· SOAP note / Adult Wellness (Annual) Checkup

Reading/Watching Material 

· Sample Note

· Watch YouTube Video

· Jarvis, C. (2016).  Physical examination & health assessment. Seventh edition. St. Louis, Mo.: Elsevier

CSLO's

· Formulate accurate differential diagnoses to promote health, prevent disease, and manage acute and chronic illness in adult and geriatric population.

· Employs screening and diagnostic strategies in the development of diagnosis.

· Demonstrate effective communication skills by performing culturally sensitive health assessment interviews 

· Critically analyze data and evidence for improving health outcomes.

EPSLO's

· Integrate nursing and related sciences into the delivery of care to clients in diverse healthcare settings

· Create effective interdisciplinary organizational and systems leadership in the care of clients in diverse care settings

· Apply practice guidelines to improve practice and health outcomes 

· Relate information and communication technologies to document and improve practice health outcomes 

· Employ collaborative interprofessional strategies for improving client and population health outcomes.  

· Evaluate the effectiveness of clinical prevention interventions that affect individual and population based-health outcomes, perform risk assessments, add design plans or programs of care.  

· Relate knowledge of illness and disease management to providing evidence-based care to clients, communities, and vulnerable populations in an evolving healthcare delivery system. 

Soap Note 1 Adult Wellness Check up 

Must use the sample template for your soap note, keep this template for your clinical rotations.

Late Assignment Policy

Assignments turned in late will have 1 point taken off for everyday assignment is late, after 7 days assignment will get a grade of 0. No exceptions 

Follow the MRU Soap Note Rubric as a guide

Use APA format and must include a minimum of 2 Scholarly Citations.

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 25% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 25%. Copy-paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.

The use of templates is ok with regards to Turn it in,  but the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient.