PRAC 6568 Week 3 Assignment 1: Developing a Focused SOAP Note

(PRAC 6568 Week 3 Assignment 1, PRAC 6568 Week 3 Assignment 1)

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?