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NSG 6020 Week 8 SOAP Note Assignment

NSG 6020 Week 8 SOAP Note Assignment

 

Each week you are required to enter your patient encounters
into CORE. Your faculty will be checking to ensure you are seeing the right
number and mix of patients for a good learning experience. Beginning in Week 5,
you will need to include one complete SOAP note each week through Week 9 for a
total of 5 complete SOAP notes for this course using this SOAP note template.
The SOAP note should be related to the content covered in this week, and the
completed SOAP note should be submitted to the Submissions Area. When
submitting your note, be sure to include the reference number from CORE where
you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into
CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document
SU_NSG6020_W8_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date
assigned.

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The SOAP note (an acronym for subjectiveobjectiveassessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient‘s chart, along with other common formats, such as the admission note.[1][2] Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing.[3] Additionally, it serves as a general cognitive framework for physicians to follow as they assess their patients.[1]

The SOAP note originated from the problem-oriented medical record (POMR), developed nearly 50 years ago by Lawrence Weed, MD.[1][4] It was initially developed for physicians to allow them to approach complex patients with multiple problems in a highly organized way.[4] Today, it is widely adopted as a communication tool between inter-disciplinary healthcare providers as a way to document a patient’s progress.[1]

SOAP notes are commonly found in electronic medical records (EMR) and are used by providers of various backgrounds.[2] Generally, SOAP notes are used as a template to guide the information that physicians add to a patient’s EMR.[2] Prehospital care providers such as emergency medical technicians may use the same format to communicate patient information to emergency department clinicians.[5] Due to its clear objectives, the SOAP note provides physicians a way to standardize the organization of a patient’s information to reduce confusion when patients are seen by various members of healthcare professionals.[2] Many healthcare providers, ranging from physicians to behavioral healthcare professionals to veterinarians, use the SOAP note format for their patient’s initial visit and to monitor progress during follow-up care.

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