Assignment Prompt & Instructions
Patient can be any pediatric age group with a respiratory disorder like asthma
– a year ago
**files (3)**
– ## SOAP1assignment.docx
– ## SOAPNoteTemplate-1.docx
– SOAPNoteRubric1.pdf
**## SOAP1assignment.docx**
A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.
**Instructions:**
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
| | |
| — | — |
| **S** = | Subjective data: Patient’s Chief Complaint (CC). |
| **O** = | Objective data: Including client behavior, physical assessment, vital signs, and meds. |
| **A** = | Assessment: Diagnosis of the patient's condition. Include differential diagnosis. |
| **P** = | Plan: Treatment, diagnostic testing, and follow up |
**Submission Instructions:**
· Your SOAP note should be clear and concise, and students will lose points for improper grammar, punctuation, and misspellings.
· You must use the template provided. Turnitin will recognize the template and not score against it.
· Complete and submit the assignment using the appropriate template in MS Word
·
**Subjective (S) – Review of Systems (ROS):**
· If the child is nonverbal or too young to describe symptoms, ensure you document statements from the guardian. Use phrases like "mother states…" or "father denies/admitted…" For example:
· "Mother denies fever, chills, or weight loss."
· "Mother admits to fever and chills, no weight loss."
·
**Social History (SH):**
· This section will also look different but still needs to be filled out. Ask the guardian about the living situation, such as:
· "Lives in an apartment with no stairs, two parents, and three siblings."
· For babies or preschoolers, you can put "N/A" for sexual orientation and work status. Instead, note their grade level. Similarly, for drug and contraceptive use, put "N/A."
· For teenagers, make sure to ask about and document information regarding sexual activity, contraceptive use, and drug use.
·
**Screening:**
· Adapt the screening section according to the child's age. While some examples in the template, like mammograms and colonoscopies, do not apply to pediatric patients, there are many age-appropriate screenings to consider:
· Newborns to 12 months
**:** Immunizations, developmental milestones, feeding screenings, hearing tests (if not completed at the hospital), etc.
· 18 to 24 months: Autism screening.
· Older than 12 years: Depression screening
· Dental exam, screening for HPV, Hep B, and HIV if high-risk behaviors.
· Teenage girls (if sexually active): Discuss the need for a pap smear and make a referral to a GYN for the first visit.
By following these guidelines, you will ensure that your SOAP notes are thorough and appropriate for pediatric patients.
**## SOAPNoteTemplate-1.docx**
| | |
| — | — |
| SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
| _Demographics_ | |
| _Chief Complaint (Reason for seeking health care)_ | |
| _History of Present Illness (HPI)_ | |
| _Allergies_ | |
| _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
| _Vital Signs_ | |
| _Labs_ | |
| _Medications_ | |
| _Past Medical History_ | |
| _Past Surgical History_ | |
| _Family History_ | |
| _Social History_ | |
| _Health Maintenance/ Screenings_ | |
| _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
| _Diagnosis_ | |
| _Differential Diagnosis_ | |
| _ICD 10 Coding_ | |
| _Pharmacologic treatment plan_ | |
| _Diagnostic/Lab Testing_ | |
| _Education_ | |
| _Anticipatory Guidance_ | |
| _Follow up plan_ | |
| _Prescription_ | See Below (scroll down) |
| _References_ | |
| _Grammar_ | |
| |
| — |
| EA#: 101010101 STU Clinic LIC# 10000000 |
| Tel: (000) 555-1234 FAX: (000) 555-12222 |
| Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |
Signature (with appropriate credentials):_____________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
**SOAPNoteRubric1.pdf**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/soapnoterubric1-pdf-10273169)
**SOAPNoteRubric1.pdf**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/soapnoterubric1-pdf-10273169)
**## SOAP1assignment.docx**
A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.
**Instructions:**
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
| | |
| — | — |
| **S** = | Subjective data: Patient’s Chief Complaint (CC). |
| **O** = | Objective data: Including client behavior, physical assessment, vital signs, and meds. |
| **A** = | Assessment: Diagnosis of the patient's condition. Include differential diagnosis. |
| **P** = | Plan: Treatment, diagnostic testing, and follow up |
**Submission Instructions:**
· Your SOAP note should be clear and concise, and students will lose points for improper grammar, punctuation, and misspellings.
· You must use the template provided. Turnitin will recognize the template and not score against it.
· Complete and submit the assignment using the appropriate template in MS Word
·
**Subjective (S) – Review of Systems (ROS):**
· If the child is nonverbal or too young to describe symptoms, ensure you document statements from the guardian. Use phrases like "mother states…" or "father denies/admitted…" For example:
· "Mother denies fever, chills, or weight loss."
· "Mother admits to fever and chills, no weight loss."
·
**Social History (SH):**
· This section will also look different but still needs to be filled out. Ask the guardian about the living situation, such as:
· "Lives in an apartment with no stairs, two parents, and three siblings."
· For babies or preschoolers, you can put "N/A" for sexual orientation and work status. Instead, note their grade level. Similarly, for drug and contraceptive use, put "N/A."
· For teenagers, make sure to ask about and document information regarding sexual activity, contraceptive use, and drug use.
·
**Screening:**
· Adapt the screening section according to the child's age. While some examples in the template, like mammograms and colonoscopies, do not apply to pediatric patients, there are many age-appropriate screenings to consider:
· Newborns to 12 months
**:** Immunizations, developmental milestones, feeding screenings, hearing tests (if not completed at the hospital), etc.
· 18 to 24 months: Autism screening.
· Older than 12 years: Depression screening
· Dental exam, screening for HPV, Hep B, and HIV if high-risk behaviors.
· Teenage girls (if sexually active): Discuss the need for a pap smear and make a referral to a GYN for the first visit.
By following these guidelines, you will ensure that your SOAP notes are thorough and appropriate for pediatric patients.
**## SOAPNoteTemplate-1.docx**
| | |
| — | — |
| SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
| _Demographics_ | |
| _Chief Complaint (Reason for seeking health care)_ | |
| _History of Present Illness (HPI)_ | |
| _Allergies_ | |
| _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
| _Vital Signs_ | |
| _Labs_ | |
| _Medications_ | |
| _Past Medical History_ | |
| _Past Surgical History_ | |
| _Family History_ | |
| _Social History_ | |
| _Health Maintenance/ Screenings_ | |
| _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
| _Diagnosis_ | |
| _Differential Diagnosis_ | |
| _ICD 10 Coding_ | |
| _Pharmacologic treatment plan_ | |
| _Diagnostic/Lab Testing_ | |
| _Education_ | |
| _Anticipatory Guidance_ | |
| _Follow up plan_ | |
| _Prescription_ | See Below (scroll down) |
| _References_ | |
| _Grammar_ | |
| |
| — |
| EA#: 101010101 STU Clinic LIC# 10000000 |
| Tel: (000) 555-1234 FAX: (000) 555-12222 |
| Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |
Signature (with appropriate credentials):_____________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
**SOAPNoteRubric1.pdf**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/soapnoterubric1-pdf-10273169)
**## SOAP1assignment.docx**
A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.
**Instructions:**
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
| | |
| — | — |
| **S** = | Subjective data: Patient’s Chief Complaint (CC). |
| **O** = | Objective data: Including client behavior, physical assessment, vital signs, and meds. |
| **A** = | Assessment: Diagnosis of the patient's condition. Include differential diagnosis. |
| **P** = | Plan: Treatment, diagnostic testing, and follow up |
**Submission Instructions:**
· Your SOAP note should be clear and concise, and students will lose points for improper grammar, punctuation, and misspellings.
· You must use the template provided. Turnitin will recognize the template and not score against it.
· Complete and submit the assignment using the appropriate template in MS Word
·
**Subjective (S) – Review of Systems (ROS):**
· If the child is nonverbal or too young to describe symptoms, ensure you document statements from the guardian. Use phrases like "mother states…" or "father denies/admitted…" For example:
· "Mother denies fever, chills, or weight loss."
· "Mother admits to fever and chills, no weight loss."
·
**Social History (SH):**
· This section will also look different but still needs to be filled out. Ask the guardian about the living situation, such as:
· "Lives in an apartment with no stairs, two parents, and three siblings."
· For babies or preschoolers, you can put "N/A" for sexual orientation and work status. Instead, note their grade level. Similarly, for drug and contraceptive use, put "N/A."
· For teenagers, make sure to ask about and document information regarding sexual activity, contraceptive use, and drug use.
·
**Screening:**
· Adapt the screening section according to the child's age. While some examples in the template, like mammograms and colonoscopies, do not apply to pediatric patients, there are many age-appropriate screenings to consider:
· Newborns to 12 months
**:** Immunizations, developmental milestones, feeding screenings, hearing tests (if not completed at the hospital), etc.
· 18 to 24 months: Autism screening.
· Older than 12 years: Depression screening
· Dental exam, screening for HPV, Hep B, and HIV if high-risk behaviors.
· Teenage girls (if sexually active): Discuss the need for a pap smear and make a referral to a GYN for the first visit.
By following these guidelines, you will ensure that your SOAP notes are thorough and appropriate for pediatric patients.
**## SOAPNoteTemplate-1.docx**
| | |
| — | — |
| SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
| _Demographics_ | |
| _Chief Complaint (Reason for seeking health care)_ | |
| _History of Present Illness (HPI)_ | |
| _Allergies_ | |
| _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
| _Vital Signs_ | |
| _Labs_ | |
| _Medications_ | |
| _Past Medical History_ | |
| _Past Surgical History_ | |
| _Family History_ | |
| _Social History_ | |
| _Health Maintenance/ Screenings_ | |
| _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
| _Diagnosis_ | |
| _Differential Diagnosis_ | |
| _ICD 10 Coding_ | |
| _Pharmacologic treatment plan_ | |
| _Diagnostic/Lab Testing_ | |
| _Education_ | |
| _Anticipatory Guidance_ | |
| _Follow up plan_ | |
| _Prescription_ | See Below (scroll down) |
| _References_ | |
| _Grammar_ | |
| |
| — |
| EA#: 101010101 STU Clinic LIC# 10000000 |
| Tel: (000) 555-1234 FAX: (000) 555-12222 |
| Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |
Signature (with appropriate credentials):_____________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
**SOAPNoteRubric1.pdf**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/soapnoterubric1-pdf-10273169)