Use the following information to document a SOAP note for the patient. Please follow the directions carefully.
Write the SOAP note in a separate Word document. Use the format learned in NSG 705 Advanced Assessment. Table 1-1 in the Bickley text that was required in the Adv Assessment course (pre-req) provides an example of a SOAP note. After documenting the subjective and objective sections using the data provided, document all problems (diagnoses) that you identify. Number each diagnosis in order of significance. Under each diagnosis include a list of differential diagnoses you considered before arriving at the identified diagnosis. After the list of differential diagnoses, list the elements of the treatment plan, specific to the identified diagnosis. Remember to include therapeutics, education, referrals, etc. when appropriate. Refer to the grading form for evaluation criteria for this assignment.
Patient Information: Jeff Wilson presents at the clinic for the first time. He is a new patient, but the scheduling clerk scheduled him for a 10-minute, problem-focused visit and the clinic is heavily booked today. Plus you have a meeting with the Hospital Credentialing Committee in the early afternoon. This patient care situation is a problem for you because you want to do a full, new-patient visit, but you don’t have enough time. You should do the best you can with the information and time you have and make a treatment plan that takes this into consideration. This means, you will have to prioritize the issues to be dealt with today.
View the encounter at
Use the information provided by the patient to document the subjective sections of the SOAP note. Some of the physical exam information is provided in the video (assume you are the provider conducting the exam). Unless a specific comment was made regarding a finding, you should document normal findings for the areas assessed. Include this information in the appropriate sections of your SOAP note. In addition, in the attached patient record you will find forms for the patient’s chart. The forms were filled out by the patient. The Best Care Clinic Intake Form was completed by the medical assistant.
