NURS 6551 Week 3 SOAP Note Assignment
Choose a affected person that you simply examined over the last three weeks. With this affected person in thoughts, tackle the next in a SOAP Note:
Subjective: What particulars did the affected person present relating to her private and medical historical past?
Goal: What observations did you make in the course of the bodily Assessment?
Assessment: What have been your differential diagnoses? Present a minimal of three doable diagnoses. Checklist them from highest precedence to lowest precedence. What was your major analysis and why?
Plan: What was your plan for diagnostics and first analysis? What was your plan for remedy and administration, together with various therapies? Embrace pharmacologic and nonpharmacologic therapies, various therapies, and follow-up parameters, in addition to a rationale for this remedy and administration plan.
Reflection notes: What would you do in a different way in an identical affected person analysis?
