Assignment SOAP Note

Purpose

Documenting, using the standard SOAP note for clinical encounters, ensures that the patient is fully assessed. The SOAP note is a best practice and is universally accepted as the documentation method for clinical encounters.

Directions

For this Assignment, you are to complete a SOAP note for a patient that you have assessed in clinical.

Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with cough and cold symptoms, you would examine the general appearance, HEENT, neck, heart, and lungs for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice. The only section that will not be included in a real chart is differential diagnosis. Remember that the differential diagnosis list includes the diagnosis you are considering.

The term “Rule Out…” cannot be used as a diagnosis.

Assignment Requirements

Before finalizing your work, you should:

• be sure to read the Assignment description carefully (as displayed above);
• utilize spelling and grammar check to minimize errors.

Your writing Assignment should:

• follow the conventions of Standard American English (correct grammar, punctuation, etc.);
• be well ordered , logical, and unified, as well as original and insightful;
• display superior content, organization, style, and mechanics; and
• use APA 6th Edition
• references less than 5 years old at least 3-5
• See attach file

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