Assignment: Academic Clinical Soap Note

Assignment: Academic Clinical Soap Note

Assignment: Academic Clinical Soap Note

ASSIGNMENT:

Assessment Description

Academic clinical SOAP notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating evidence-based plans of care.

This assignment uses a template. Refer to the “Academic SOAP Note Template,” located on the college page of the Student Success Center under the AGACNP tab.

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Develop a hospital follow-up progress SOAP note based on a clinical patient from your clinical/practicum setting. In your assessment, provide the following:

A one-sentence description of the primary working diagnosis, pending differential diagnoses, and the context or service in which the patient is being seen.
A one- or two-paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures. Include how many days the patient has been hospitalized, if applicable.
List of at least five systems affected by the working diagnosis. Provide two positive or negative effects that the working diagnosis has on each system.
List of at least five systems examined within the past 24 hours. Provide at least two pertinent positive or negative findings relevant to each system examined and include a full set of vital signs.
List of all admission diagnostics conducted for this visit or conducted within the past 24 hours.
List of all pertinent acute and chronic diagnoses in order of priority using ICD-10. Identify any differential diagnoses being eliminated.
Treatment plan that corresponds with the diagnosis. Provide information on admission type, types of diagnostics, any prescribed medications and dosages, and any relevant consults or follow-up procedures needed.
Discussion of any relevant ethical, legal, or geriatric-specific considerations.
Incorporate at least three peer-reviewed articles in the assessment or plan.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite Technical Support Articles is located in Class Resources if you need assistance.

Sickle cell anemia crisis w/pain

-Hgb 4.8 on admission

-s/p 1-unit PRBC 1/23

-transfuse if hgb <5 per Dr. Flaherty hem/onc recs

-NS 0.45%

-folic acid daily

-pain control

-IV morphine

-resumed home meds MS Contin Q12H and OXY IR Q4H

-tylenol PRN

-Dr. Flaherty hem/onc consulted