nurs 6531 soapnote 1
ziyeyixsyAssignment: Practicum Experience – SOAP Note and Journal
After completing this week’s Practicum Experience, select a patient that you examined during the last 3 weeks.
With this patient in mind, address the following in a SOAP Note:
· 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?
· 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?
· Reflection notes: What would you do differently in a similar patient evaluation?
- 8 years ago
- 10
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- soap_note_and_journal_rev.docx
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