Assignment SOAP Note
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.
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.
Before finalizing your work, you should: