SOAP Note
SOAP Note Write Up for VR Patient Anna Jones
Demonstrate your ability to provide age-appropriate anticipatory guidance while recognizing the need to refer patients that are outside of the scope of practice of the family nurse practitioner.
This will be demonstrated by completing a SOAP note based on a patient Anna Jones seen in Unit 6 in the VR platform.
Write-ups
The core aspects of the SOAP note are described in detail below.
For ease of learning, a SOAP Note Template has been provided. For this assignment, proper citation and referencing is required because this is an academic paper.
S: Subjective information. Everything the patient tells you. This includes several areas including the chief complaint (CC), the history of present illness (HPI), medical history, surgical history, family history, social history, medications, allergies, and other information gathered from the patient. A commonly used mnemonic to explore the core elements of the history of present illness (HPI) is OLD CARTS, which includes: Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatments, and Severity.
O: Objective is what you see, hear, feel or smell. Your physical exam including vital signs.
A: Assessment/ Your differentials
P: Plan of care including health promotion and disease prevention for the patient related to their age and gender.
If there are any questions, please contact your instructor.
DUE: to the Journal Dropbox by end of the unit week, end of day (EOD) Tuesday.
To view the Grading Rubric for this assignment, please visit the Grading Rubrics section of Course Resources.
