After completing this week’s Practicum Experience, select a patient whom you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:
- 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?
- 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 was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies?
- Reflection notes: What would you do differently in a similar patient evaluation?
Please refer to the Learning Resources in Week 3 for guidance on writing SOAP Notes.