Focused Soap Note

Description

Overview

A focused SOAP note is a written record of your encounter with a patient that only assesses those systems that pertain to the complaint. The purpose of writing episodic SOAP notes is to ensure you meet competencies related to gathering problem-specific health histories and synthesizing physical examination data needed to formulate a plan of care. Through this assignment, you will gain experience in formulating a plan based upon specific patient information and communicating the plan in a clear and organized manner.

When completing your SOAP note:

• Your patient should be at least 50 years old and have at least one chronic health problem.
• Be sure to complete ALL parts of the plan, whether they apply or not. For example, if you do not need to assess a particular system, write “Deferred” in the associated blank. For another example, if it is not necessary to refer your patient, be sure to write “None” next to referral. In sum, do not leave blanks on any parts of the plan!
• Do NOT document “WNL” (within normal limits) or “unremarkable.” Be sure to describe your findings appropriately, even if normal.
• You should use at least two scholarly resources to obtain the necessary clinical information to develop the assessment and treatment plan. You may use your Dains’ textbook and one other scholarly reference of your choice. Format your references in APA format.
• Refer to the assignment rubric prior for more specific details.

How to Use the SOAP Note Tool

The SOAP Note Tool is a step-by-step form that you can fill out to easily draft your SOAP note. Some fields will have an “i” icon next to them. Hovering over the “i” icon will provide critical information for filling out that field. When you complete the SOAP note, you will have the ability to save it as a Word document. Be sure to review your SOAP note and make any necessary edits before submitting your assignment in Canvas.

Click on the button below to access the SOAP Note Tool.