Personal and Medical History Paper
In addition to Journal Entries, Focused SOAP Note submissions are a way to reflect on your Practicum Experiences and connect these experiences to your classroom experience. Focused SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Please refer to this week’s Learning Resources for guidance on writing Focused SOAP Notes. Select a patient that you examined during the last two weeks. With this patient in mind, address the following in a Focused SOAP Note: Subjective: What details did the patient provide regarding her personal and medical history? Personal and Medical History Paper
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Objective: What observations did you make during the physical assessment? Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why? Plan: What were your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Reflection notes: What would you do differently in a similar patient evaluation? Personal and Medical History Paper
