Walden NURS 6565 Week 3 Assignment 1

Assignment 1: Developing a Focused SOAP Note

In this concentrated SOAP note project, you will be able to reflect on your Practicum experiences and make connections between them and your classroom experiences. Clinical settings frequently employ focused SOAP notes to document the treatment provided to their patients. When gathering patient information, they adhere to a consistent, methodical approach. You will be required to utilize a Word document template in this course and document everything manually, in a similar way to how you would learn to do math problems by hand before using a calculator. It is possible that you may come across electronic health record systems that have SOAP documentation capabilities such as search functions and symptom drag and drops that will ease the process later in your career.

 The signature and initials of your preceptor are required on all SOAP notes, as well as on each page. It is necessary to submit your SOAP Note in two formats: as a Word document including the entire SOAP Note, and as a pdf or image of each page that has been initialed and signed by your preceptor. SafeAssign must be used to submit your SOAP Note.

Please keep in mind that electronic signatures will not be accepted in this situation. if the files are not received by the due date, the faculty will subtract points in accordance with the Walden Late Policy.

Assignment1 (percentage of total) is to be completed as soon as possible.

 

Examine the Learning Resources for this week, which include the Focused SOAP Note Template.

Please choose a patient who you have seen at your practicum site during the last three weeks. Consider the following scenarios in light of this patient:
The patient's personal and medical history is subjective; what information did he or her supply is subjective.
Objective: During the physical evaluation, what observations did you make? Include any relevant positive and negative findings from a physical exam in your submission. Include a description of any morbidities or psychosocial difficulties that the patient has exhibited.
Affirmation: What were some of your possible diagnoses? Include as many possible diagnoses as you can think of. Include their ICD-10 diagnosis code and arrange them in descending order from highest to lowest importance. When you were diagnosed, what was the primary reason for your diagnosis?
How did you envision approaching diagnostics and initial diagnosis? When it came to treatment and management, what did you have in mind. Please include all medications and non-prescription medications, alternative therapies and follow-up metrics as well as a justification for your treatment and management strategy.
Notes for reflection: When did you have a "aha" experience? When evaluating a similar patient, what would you do differently? You can choose any heart disease sufferer or any patient with diabetes.

Week 3: Creating a Focused SOAP Notification
What exactly am I supposed to do?
When am I required to complete it?
Take a look at your Learning Resources.
Days 1–7 of the week
Assignment 1: Create a SOAP note that is focused on a specific issue
Completed by the 7th day.
a second assignment involving clinical hours and patient logs
By Day 7, you should have recorded your clinical hours and patient contacts in Meditrek.
Take a look back at the experiences you've had so far, whether they've been in the healthcare workplace or at your practicum location. The role of a nurse does not begin and end with one-on-one patient contact, as you are most likely aware of. Meetings, paperwork, training, and collaboration are all part of the process. In particular, the nurse is a member of an interdisciplinary team and is responsible for communicating with others about the condition of a patient, both verbally and in writing. An advanced practice nurse's ability to capture and communicate a patient's history, symptoms, diagnosis, and treatment plan to relevant individuals involved in the patient's care is therefore a critical competency.

The SOAP note on one of the patients with whom you have engaged during your clinical practicum will be developed this week in addition to your Meditrek tracking.

Objectives for Learning
Students will be able to:

• Patients in primary care settings should be evaluated.

• In primary care settings, develop differential diagnoses for patients who present with a variety of symptoms.

• Create treatment plans for patients who are seen in basic health care settings.

• Explanation of clinical hours as well as patient encounters