Students will complete 4 Focused SOAP notes on three different patients and three different diagnoses that have been pre-selected for you. For this SOAP you have the opportunity of selecting a GI condition (Acute or Chronic) of your choice. I look forward to seeing what you select. Visits for refills of medications are not acceptable for this assignment.
All aspects of the SOAP must be completed. Your faculty will give feedback on the SOAP assignment. Students are expected to incorporate feedback into subsequent SOAP note assignments and build their knowledge base. Students are encouraged to practice a habit of completing notes as soon as possible, ideally on the same clinical day. A professional NP in practice must complete multiple notes daily. Prompt documentation is the standard of professionalism we encourage.
Instructions:
1. Review the SOAP Guidance page.
This SOAP must be completed on a patient that is being seen for a routine yearly wellness exam. You will be required to address every body system in both the Subjective and Objective sections of your SOAP note. Yearly wellness visits are typically visits that take 30+ minutes if done right. They include yearly labwork/diagnostics, preventive care, wellness promotion, a lot of education, etc. They are not episodic visits where you address only the chief complaints and what may stand out during the visit (15-minute visits).
2. When submitting your SOAP do not include the guidance or pointers provided to you that are found in italics or within parentheses.
These are to provide you with guidance only.
3. When you receive your graded SOAPs ensure to review the feedback provided. We do go back to the previous SOAP to ensure you are applying our guidance and not overlooking it.
4. Pay close attention to the due dates.
5. Be advised that these SOAPs will not mirror what you see in your EMRs.
6. The Clinical Decision Process is very important. Do not take it lightly. This section is designed to further assist in your learning from this patient case and disease process. Ensure to address the questions in their entirety.
7. Review and refresh your memory with what is Subjective and Objective information before diving into the SOAP. Go back to the basics if you must.
8. References used in your H&P should be in a reference page and in APA format. You need a MINIMUM of 3 professional peer reviewed references (course texts, professional articles and publications. No patient information sites like Mayo, Cleveland Clinic….)
9. Do not forget to look at the Rubric.
10. H&Ps/SOAPs must be the student’s own work. If sections of the H&P are not the student’s work, for example, from a preceptor’s note it should be identified by italics. A SOAP template is provided. No identifying information should be included in the note, which would be considered a HIPPA violation.
11. H&P notes submitted for the course include more information than the notes that students may submit in clinical. The submitted note is used for coaching and evaluation of the student’s progress in developing clinical and diagnostic thinking.
12. Late assignments will not be accepted.