Practicum Experience: SOAP Note and Time Log

In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum Experiences and connect these experiences to your classroom experience. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Please refer to the Seidel, et. al. book excerpt and the Gagan article located in this week’s Learning Resources for guidance on writing SOAP Notes.
After completing this week’s Practicum Experience, You evaluated a patient with hypertension. With this patient in mind, address the following in a SOAP Note:
1).Subjective: What details did the patient provide regarding his or her personal and medical history?
2).Objective: What observations did you make during the physical assessment?
3).Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
4).Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies?
5).Reflection notes: What would you do differently in a similar patient evaluation?

Readings Resources:
• Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2013). Primary care: A collaborative practice (4th ed.). St. Louis, MO: Mosby.
o Part 11, “Evaluation and Management of Cardiovascular Disorders” (pp. 487–611)

This part explores diagnostics of cardiovascular disorders, including how to differentiate between normal and abnormal test results. It also examines how patient history and physical exams contribute to differential diagnoses for cardiovascular disorders.
• Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Mosby.
o Chapter 26, “Recording Information”

This chapter outlines the components of SOAP notes and provides guidelines for writing SOAP notes after patient examinations. Please note: You should have this textbook in your personal library, as it was the required text in NURS 6511: Advanced Health Assessment & Diagnostic Reasoning.
• Gagan, M. J. (2009). The SOAP format enhances communication. Nursing New Zealand, 15(5), 15.
Retrieved from the Collage Library databases.

This article outlines the four parts of SOAP notes and examines the importance and effectiveness of SOAP notes in clinical settings.
• National Heart Lung and Blood Institute. (2002). Primary prevention of hypertension: Clinical and public health advisory from the National High Blood Pressure Education Program. Retrieved from https://www.nhlbi.nih.gov/health/prof/heart/hbp/pphbp.pdf

this article reviews factors that impact the patient education of hypertension. Hypertension prevention and intervention methods are also explored.


 

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