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 |
- Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.
- You must use the template provided.
- please provide plagiarism report
- please provide ai report
The patient is a white female age 45 . her initials are S.P. She has these diagnosis Z00.01 – Encounter for general adult medical examination with abnormal findingse, I10. – Essential (primary) hypertension, E78.5 – Hyperlipidemia, unspecifiede, and E11.0 DM without complication . everything else can be made up according to these diagnosis she does see endocrinologist doctor and referral was provided as well and medication refillsThe last soap note you helped me with scored 100%
I have attached the template needed to be used and also the rubric for the assignment.
Requirements: soap note
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