Follow the rubric to develop your SOAP note for this assignment. The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages. You are required to provide a list of differential diagnoses (at least 3) with evidence-based explanations of “why” they fit your patient’s illness scenario and “how” you determined the working diagnosis. The plan will include the management portion and may include diagnostic or screening tests (where appropriate), non-pharmacological and pharmacological interventions, patient education and health promotion, follow-up, and referral or consultation (where appropriate).
Please note, the details in your SOAP note can vary from what Cyberpatient identifies as a “right” answer. As long as your rationale is clear, your diagnostic or screening tests, interventions and referral/consultation sections may and can be different.
Your assignment must include the following:
- Chief Complaint
- History of Present Illness
- Past Medical History (including immunizations)
- Allergies (Medication, Food, Environmental)
- Medications, dosages, and indications (including herbals, supplements, and OTCs)
- Family History
- Social History
- Review of Systems (systematic and relevant to focused visit)
- Physical Examination
- Lab results (where applicable)
- Differential diagnoses (at least 3) with a brief evidence-based explanation of how they were determined and how they apply to this patient specifically
- Working diagnosis with evidence-based explanation of how this was determined
- Management plan including diagnostic or screening tests (where appropriate), non-pharmacological and pharmacological interventions, patient education and health promotion, follow-up, and referral or consultation (where appropriate).
- Date, time, signature and designation
Your assignment must demonstrate the following:
- Ethical concepts of good practice such as respect, informed decision-making, and promoting health and well-being.
- Safe, competent care that meets acceptable standards of care.
- A note that is well organized, contains correct spelling, demonstrates a professional tone and medical terminology, and avoidance of error prone abbreviations, symbols, and acronyms.
- Clear, concise, unbiased, and accurate documentation.
- Findings are documented in the correct sections (subjective, objective, assessment, and plan).
- Title page in APA (7th ed.). format
- In-text citations and reference list as per APA (7th ed.)
Requirements: 1000-1500
