Assessing Care Plan For Patient

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Assessing Care Plan For Patient

Assessing Care Plan For Patient

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Week 4 assignment 1

Assignment: Practicum – Week 3 SOAP Note

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. Refer to this week’s Learning Resources for guidance on writing SOAP Notes.

Select a geriatric patient that you examined during the last 3 weeks. The patient you select should be currently taking at least five prescription and/or over-the-counter drugs. With this patient in mind, address the following in a SOAP Note:

Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding his or her personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list with the Beers Criteria and consider alternative drugs if appropriate.

Objective: What observations did you make during the physical assessment? What functional assessments were used?

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from top priority to least priority.

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies? What is your care plan for the patient? How would you offer caregiver support?

Reflection notes: What would you do differently in a similar patient evaluation? How might you improve your assessment, diagnosis, and/or plan through interprofessional collaboration?

Refer to this week’s Learning Resources for guidance on writing SOAP Notes.

By Day 7 of Week 4

This Assignment is due. You will submit this Week 3 SOAP Note along with your Journal Entries (from Weeks 1, 2, and 4) by Day 7 of Week 4.

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