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Assignment: PRAC 6568 Week 3 Developing a Focused SOAP Note

Assignment: PRAC 6568 Week 3 Developing a Focused SOAP Note

Assignment: PRAC 6568 Week 3 Developing a Focused SOAP Note

Developing a Focused SOAP Note

This focused SOAP note assignment is a way to reflect on your Practicum experiences and connect them to your classroom experience. Focused SOAP notes are often used in clinical settings to document patient care. They provide a standard, systematic format for collecting patient information. Similar to learning to compute math problems by hand before you move to a calculator, you are required to use a Word document template in this course and document everything manually. In your career, however, you are likely to encounter electronic health record systems with SOAP documentation capabilities such as search functions and symptom drag and drops that will streamline the process.

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All SOAP notes must be signed and each page must be initialed by your preceptor. When you submit your SOAP Note, you should include the complete SOAP Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your SOAP Note using SafeAssign.

Please Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.

Resources

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

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WEEKLY RESOURCES

Learning Resources

Required Readings

Recommended Media

  • Fowler, G. C. (2019). Pfenninger and Fowler’s procedures for primary care (4th ed.). Elsevier.
    • Ch. 57, “Chalazion and Hordeolum”
    • Ch. 62, “Cerumen Impaction Removal”
    • Ch. 200, “Corneal Abrasions and Removal of Corneal or Conjunctival Foreign Bodies”
    • Ch. 205, “Management of Epistaxis”

To prepare:

  • Review this week’s Learning Resources, including the Focused SOAP Note Template.
  • 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?

By Day 7

Submit your Assignment. You must submit two files for the SOAP note, including a Word document and scanned pdf/images of each page that is initialed and signed by your preceptor.

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

  1. To submit your completed assignment, save your Assignment as WK3Assgn1+last name+first initial.
  2. Then, click on Start Assignment near the top of the page.
  3. Next, click on Upload File and select Submit Assignment for review.

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Rubric

PRAC_6568_Week3_Assignment1_Rubric

PRAC_6568_Week3_Assignment1_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about the patient you selected. In the Subjective section, provide: • Chief complaint • History of present illness (HPI) • Current medications • Allergies • Patient medical history (PMHx), including immunization status, social and substance history, family history, past surgical procedures, mental health, safety concerns, reproductive history • Review of systems
10 to >8.0 ptsExcellent

The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis.

 8 to >7.0 ptsGood

The response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis.

 7 to >6.0 ptsFair

The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies.

 6 to >0 ptsPoor

The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeIn the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
10 to >8.0 ptsExcellent

The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

 8 to >7.0 ptsGood

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.

 7 to >6.0 ptsFair

Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.

 6 to >0 ptsPoor

The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeIn the Assessment section, provide: • At least 3 differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.
25 to >22.0 ptsExcellent

The response lists at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected.

 22 to >19.0 ptsGood

The response lists at least three different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the conditions selected.

 19 to >17.0 ptsFair

The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.

 17 to >0 ptsPoor

The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
25 pts
This criterion is linked to a Learning OutcomeIn the Plan section, provide: • A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. • Reflections on the case describing insights or lessons learned. • A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors.
30 to >26.0 ptsExcellent

The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. Reflections on the case demonstrate strong critical thinking and synthesis of ideas. A thorough and accurate disucssion of health promotion and disease prevention related to the case is provided.

 26 to >23.0 ptsGood

The response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. Reflections on the case demonstrate critical thinking. An accurate disucssion of health promotion and disease prevention related to the case is provided.

 23 to >20.0 ptsFair

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. Reflections on the case demonstrate adequate understanding of course topics. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies.

 20 to >0 ptsPoor

The response does not address all diagnoses or is missing elements of the treatment plan. Reflections on the case are vague or missing. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing.
30 pts
This criterion is linked to a Learning OutcomeProvide at least three evidence-based, peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than five years old) and support the treatment plan in following current standards of care.
10 to >8.0 ptsExcellent

The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions.

 8 to >7.0 ptsGood

The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions.

 7 to >6.0 ptsFair

Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan.

 6 to >0 ptsPoor

Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence-based, or do not support the treatment plan.
10 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 to >4.0 ptsExcellent

Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

 4 to >3.5 ptsGood

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

 3.5 to >3.0 ptsFair

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment is vague or off topic.

 3 to >0 ptsPoor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time. No purpose statement, introduction, or conclusion were provided.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation
5 to >4.0 ptsExcellent

Uses correct grammar, spelling, and punctuation with no errors.

 4 to >3.5 ptsGood

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

 3.5 to >3.0 ptsFair

Contains several (3 or 4) grammar, spelling, and punctuation errors.

 3 to >0 ptsPoor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
5 to >4.0 ptsExcellent

Uses correct APA format with no errors.

 4 to >3.5 ptsGood

Contains a few (1 or 2) APA format errors.

 3.5 to >3.0 ptsFair

Contains several (3 or 4) APA format errors.

 3 to >0 ptsPoor

Contains many (≥ 5) APA format errors.
5 pts
Total Points: 100 


		

						

					

		

					

		

				

				

																														

				

				

		

					

				

				

			
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